28 CA ADC § 1300.68.01
28 CCR s 1300.68.01
Cal. Admin. Code tit. 28, s 1300.68.01
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.68.01. Expedited Review of Grievances.
(a) Every plan shall include in its grievance system, procedures for the
expedited review of grievances involving an imminent and serious threat to
the health of the enrollee, including, but not limited to, severe pain,
potential loss of life, limb or major bodily function ( "urgent
grievances"). At a minimum, plan procedures for urgent grievances shall
include:
(1) Immediate notification to the complainant of the right to contact the
Department regarding the grievance. The plan shall expedite its review of
the grievance when the complainant, an authorized representative, or
treating physician provides notice to the plan. Notice need not be in
writing, but may be accomplished by a documented telephone call.
(2) A written statement to the Department and the complainant on the
disposition or pending status of the urgent grievance within three (3)
calendar days of receipt of the grievance by the Plan.
(3) Consideration by the plan of the enrollee's medical condition when
determining the response time.
(4) No requirement that the enrollee participate in the plan's grievance
process prior to applying to the Department for review of the urgent
grievance.
(b) Each plan's grievance system shall allow for the Department to contact
the plan regarding urgent grievances 24 hours a day, 7 days a week. During
normal work hours, the plan shall respond to the Department within 30
minutes after initial contact from the Department. During non-work hours,
the plan shall respond to the Department within 1 hour after initial
contact from the Department.
(1) The system established by the plan shall provide for the availability
of a plan representative with authority on the plan's behalf to resolve
urgent grievances and authorize the provision of health care services
covered under the enrollee's plan contract in a medically appropriate and
timely manner. Such authority shall include making financial decisions for
expenditure of funds on behalf of the plan without first having to obtain
approval from supervisors or other superiors within the plan. Nothing in
this subsection shall restrict the plan representative from consulting
with other plan staff on urgent grievances.
(2) Plans shall provide the Department with the following information
concerning urgent grievances:
(A) A description of the system established by the plan to resolve urgent
grievances. The description shall include the system's provisions for
scheduling qualified plan representatives, including back-up plan
representatives as necessary, to be available twenty-four (24) hours a
day, seven days a week to respond to Department contacts regarding urgent
grievances. Provisions for scheduling shall include the names and titles
of those plan representatives who will be available under the system,
their telephone numbers, and, as applicable, pager numbers, answer service
numbers, voice-mail numbers, e-mail addresses, or other means for contact.
(B) A description of how the Department may access the grievance system
established by the plan.
(3) If the plan revises the system established pursuant to subsection (b),
the plan shall notify the Department at least thirty (30) days in advance
of implementing the revisions.
(c) The plan shall notify the Department before changing or modifying any
benefit or services that relates to the urgent grievance submitted to the
Department pursuant to subsection (b)(1)(A) of section 1368 of the Act if
the enrollee or the enrollee's representative objects to the change or
modification.
Note: Authority cited: Section 1344, Health and Safety Code; Reference:
Sections 1368 and 1368.01, Health and Safety Code.
HISTORY
1. New section filed 5-30-2000 as an emergency; operative 5-30-2000
(Register
2000, No. 22). A Certificate of Compliance must be transmitted to OAL by
9-
27-2000 or emergency language will be repealed by operation of law on the
following day.
2. Repealer filed 8-14-2000 (Regulatory Action No. 00-0807-01E) as an
emergency; operative 8-14-2000 (Register 2000, No. 33). A Certificate of
Compliance must be transmitted to OAL by 12-12-2000 or emergency language
will
be repealed by operation of law on the following day.
3. New section filed 8-14-2000 (Regulatory Action No. 00-0807-02E) as an
emergency; operative 8-14-2000 (Register 2000, No. 33). A Certificate of
Compliance must be transmitted to OAL by 12-12-2000 or emergency language
will
be repealed by operation of law on the following day.
4. Editorial correction of History2and History3 (Register 2001, No. 2).
5. Certificate of Compliance as to 8-14-2000 order (Regulatory Action No.
00-
0807-01E) transmitted to OAL 11-29-2000 and filed 1-10-2001 (Register
2001,
No. 2).
6. Certificate of Compliance as to 8-14-2000 order (Regulatory Action No.
00-
0807-02E), including amendment, transmitted to OAL 11-29-2000 and filed
1-10-
2001 (Register 2001, No. 2).
7. Repealer and new section filed 11-12-2002; operative 12-12-2002
(Register
2002, No. 46).
28 CA ADC s 1300.68.01
END OF DOCUMENT
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