28 CA ADC § 1300.68
28 CCR s 1300.68
Cal. Admin. Code tit. 28, s 1300.68
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. Grievance System.
Every health care service plan shall establish a grievance system pursuant
to the requirements of Section 1368 of the Act.
(a) The grievance system shall be established in writing and provide for
procedures that will receive, review and resolve grievances within 30
calendar days of receipt by the plan, or any provider or entity with
delegated authority to administer and resolve the plan's grievance system.
The following definitions shall apply with respect to the regulations
relating to grievance systems:
(1) "Grievance" means a written or oral expression of dissatisfaction
regarding the plan and/or provider, including quality of care concerns,
and shall include a complaint, dispute, request for reconsideration or
appeal made by an enrollee or the enrollee's representative. Where the
plan is unable to distinguish between a grievance and an inquiry, it shall
be considered a grievance.
(2) "Complaint" is the same as "grievance."
(3) "Complainant" is the same as "grievant," and means the person who
filed the grievance including the enrollee, a representative designated by
the enrollee, or other individual with authority to act on behalf of the
enrollee.
(4) "Resolved" means that the grievance has reached a final conclusion
with respect to the enrollee's submitted grievance, and there are no
pending enrollee appeals within the plan's grievance system, including
entities with delegated authority.
(A) If the plan has multiple internal levels of grievance resolution or
appeal, all levels must be completed within 30 calendar days of the plan's
receipt of the grievance.
(B) Grievances that are not resolved within 30 calendar days, or
grievances referred to the Department's complaint or independent medical
review system, shall be reported as "pending" grievances pursuant to
subsection (f) below. Grievances referred to external review processes,
such as reviews of Medicare Managed Care determinations pursuant to 42
C.F.R. Part 422, or the Medi-Cal Fair Hearing process, shall also be
reported pursuant to subsection (f) until the review and any required
action by the plan resulting from the review is completed.
(b) The plan's grievance system shall include the following:
(1) An officer of the plan shall be designated as having primary
responsibility for the plan's grievance system whether administered
directly by the plan or delegated to another entity. The officer shall
continuously review the operation of the grievance system to identify any
emergent patterns of grievances. The system shall include the reporting
procedures in order to improve plan policies and procedures.
(2) Each plan's obligation for notifying subscribers and enrollees about
the plan's grievance system shall include information on the plan's
procedures for filing and resolving grievances, and the telephone number
and address for presenting a grievance. The notice shall also include
information regarding the Department's review process, the independent
medical review system, and the Department's toll-free telephone number and
website address.
(3) The grievance system shall address the linguistic and cultural needs
of its enrollee population as well as the needs of enrollees with
disabilities. The system shall ensure all enrollees have access to and can
fully participate in the grievance system by providing assistance for
those with limited English proficiency or with a visual or other
communicative impairment. Such assistance shall include, but is not
limited to, translations of grievance procedures, forms, and plan
responses to grievances, as well as access to interpreters, telephone
relay systems and other devices that aid disabled individuals to
communicate. Plans shall develop and file with the Department a policy
describing how they ensure that their grievance system complies with this
subsection within 90 days of the effective date of this regulation.
(4) The plan shall maintain a toll-free number, or a local telephone
number in each service area, for the filing of grievances.
(5) A written record shall be made for each grievance received by the
plan, including the date received, the plan representative recording the
grievance, a summary or other document describing the grievance, and its
disposition. The written record of grievances shall be reviewed
periodically by the governing body of the plan, the public policy body
created pursuant to section 1300.69, and by an officer of the plan or his
designee. This review shall be thoroughly documented.
(6) The plan grievance system shall ensure that assistance in filing
grievances shall be provided at each location where grievances may be
submitted. A "patient advocate" or ombudsperson may be used.
(7) Grievance forms and a description of the grievance procedure shall be
readily available at each facility of the plan, on the plan's website, and
from each contracting provider's office or facility. Grievance forms shall
be provided promptly upon request.
(8) The plan shall assure that there is no discrimination against an
enrollee or subscriber (including cancellation of the contract) on the
grounds that the complainant filed a grievance.
(9) The grievance system shall allow enrollees to file grievances for at
least 180 calendar days following any incident or action that is the
subject of the enrollee's dissatisfaction.
(c) Through periodic medical surveys under Section 1380 of the Act, the
Department shall periodically review the plan's grievance system,
including the records of grievances received by the plan, and assess the
effectiveness of the plan policies and actions taken in response to
grievances.
(d) The plan shall respond to grievances as follows:
(1) A grievance system shall provide for a written acknowledgment within
five (5) calendar days of receipt, except as noted in subsection (d)(8).
The acknowledgment will advise the complainant that the grievance has been
received, the date of receipt, and provide the name of the plan
representative, telephone number and address of the plan representative
who may be contacted about the grievance.
(2) The grievance system shall provide for a prompt review of grievances
by the management or supervisory staff responsible for the services or
operations which are the subject of the grievance.
(3) The plan's resolution, containing a written response to the grievance
shall be sent to the complainant within thirty (30) calendar days of
receipt, except as noted in subsection (d)(8). The written response shall
contain a clear and concise explanation of the plan's decision. Nothing in
this regulation requires a plan to disclose information to the grievant
that is otherwise confidential or privileged by law.
(4) For grievances involving delay, modification or denial of services
based on a determination in whole or in part that the service is not
medically necessary, the plan shall include in its written response, the
reasons for its determination. The response shall clearly state the
criteria, clinical guidelines or medical policies used in reaching the
determination. The plan's response shall also advise the enrollee that the
determination may be considered by the Department's independent medical
review system. The response shall include an application for independent
medical review and instructions, including the Department's toll-free
telephone number for further information and an envelope addressed to the
Department of Managed Health Care, HMO Help Center, 980 Ninth Street, 5th
Floor, Sacramento, CA 95814.
(5) Plan responses to grievances involving a determination that the
requested service is not a covered benefit shall specify the provision in
the contract, evidence of coverage or member handbook that excludes the
service. The response shall either identify the document and page where
the provision is found, direct the grievant to the applicable section of
the contract containing the provision, or provide a copy of the provision
and explain in clear concise language how the exclusion applied to the
specific health care service or benefit requested by the enrollee. In
addition to the notice set forth at Section 1368.02(b) of the Act, the
response shall also include a notice that if the enrollee believes the
decision was denied on the grounds that it was not medically necessary,
the Department should be contacted to determine whether the decision is
eligible for an independent medical review.
(6) Copies of grievances and responses shall be maintained by the Plan for
five years, and shall include a copy of all medical records, documents,
evidence of coverage and other relevant information upon which the plan
relied in reaching its decision.
(7) The Department's telephone number, the California Relay Service's
telephone numbers, the plan's telephone number and the Department's
Internet address shall be displayed in all of the plan's acknowledgments
and responses to grievances in 12-point boldface type with the statement
contained in subsection (b) of Section 1368.02 of the Act.
(8) Grievances received over the telephone that are not coverage disputes,
disputed health care services involving medical necessity or experimental
or investigational treatment, and that are resolved by the close of the
next business day, are exempt from the requirement to send a written
acknowledgment and response. The plan shall maintain a log of all such
grievances containing the date of the call, the name of the complainant,
member identification number, nature of the grievance, nature of
resolution, and the plan representative's name who took the call and
resolved the grievance. The information contained in this log shall be
periodically reviewed by the plan as set forth in subsection (b).
(e) The plan's grievance system shall track and monitor grievances
received by the plan, or any entity with delegated authority to receive or
respond to grievances. The system shall:
(1) Monitor the number of grievances received and resolved; whether the
grievance was resolved in favor of the enrollee or plan; and the number of
grievances pending over 30 calendar days. The system shall track
grievances under categories of Commercial, Medicare and Medi-Cal/other
contracts. The system shall indicate whether an enrollee grievance is
pending at: (1) the plan's internal grievance system; (2) the Department's
consumer complaint process; (3) the Department's Independent Medical
Review system; (4) an action filed or before a trial or appellate court;
or (5) other dispute resolution process. Additionally, the system shall
indicate whether an enrollee grievance has been submitted to: (1) the
Medicare review and appeal system; (2) the Medi-Cal fair hearing process;
or (3) arbitration.
(2) The system shall be able to indicate the total number of grievances
received, pending and resolved in favor of the enrollee at all levels of
grievance review and to describe the issue or issues raised in grievances
as (1) coverage disputes, (2) disputes involving medical necessity, (3)
complaints about the quality of care and (4) complaints about access to
care (including complaints about the waiting time for appointments), and
(5) complaints about the quality of service, and (6) other issues.
(f) Quarterly Reports
(1) All plans shall submit a quarterly report to the Department describing
grievances that were or are pending and unresolved for 30 days or more.
The report shall be prepared for the quarters ending March 31st, June
30th, September 30th and December 31st of each calendar year. The report
shall also contain the number of grievances referred to external review
processes, such as reconsiderations of Medicare Managed Care
determinations pursuant to 42 C.F.R. Part 422, the Medi-Cal fair hearing
process, the Department's complaint or Independent Medical Review system,
or other external dispute resolution systems, known to the plan as of the
last day of each quarter.
(2) The quarterly report shall include:
(A) The licensee's name, quarter and date of the report;
(B) The total number of grievances filed by enrollees that were or are
pending and unresolved for more than 30 calendar days at any time during
the quarter under the categories of Commercial, Medicare, and
Medi-Cal/other products offered by the plan;
(C) A brief explanation of why the grievance was not resolved in 30 days,
and indicate whether the grievance was or is pending at: (1) the plan's
internal grievance system; (2) the Department's consumer complaint
process; (3) the Department's Independent Medical Review system; (4)
court; or (5) other dispute resolution processes. Alternatively, the plan
shall indicate whether the grievance was or is submitted to: (1) the
Medicare review and appeal system; (2) the Medi-Cal fair hearing process;
or (3) arbitration.
(D) The nature of the unresolved grievances as (1) coverage disputes; (2)
disputes involving medical necessity; (3) complaints about the quality of
care; (4) complaints about access to care (including complaints about the
waiting time for appointments); (5) complaints about the quality of
service; and (6) other issues. All issues reasonably described in the
grievance shall be separately categorized.
(E) The quarterly report shall not contain personal or confidential
information with respect to any enrollee.
(3) The quarterly report shall be verified by an officer authorized to act
on behalf of the plan. The report shall be submitted in writing or through
electronic filing to the Department's Sacramento Office to the attention
of the Filing Clerk no later than 30 days after each quarter. The
quarterly report shall not be filed as an amendment to the plan
application.
(4) The quarterly report shall be filed in the format specified in
subsection (i).
(g) An enrollee may submit a grievance to the Department. The Department
shall notify the plan, and within five (5) calendar days after
notification, the plan shall provide the following information to the
Department:
(1) A written response to the issues raised by the grievance.
(2) A copy of the plan's original response sent to the enrollee regarding
the grievance.
(3) A complete and legible copy of all medical records related to the
grievance. The plan shall inform the Department if medical records were
not used by the plan in resolving the grievance.
(4) A copy of the cover page and all relevant pages of the enrollee's
Evidence of Coverage (EOC), with the specific applicable sections
underlined. If the plan relied solely on the EOC, the plan shall notify
the Department of that fact.
(5) All other information used by the plan or relevant to the resolution
of the grievance.
(6) The Department may request additional information or medical records
from the plan. Within five (5) calendar days of receipt of the
Department's request, the plan shall forward information and records that
are maintained by the plan or any contracting provider. If requested
information cannot be timely forwarded to the Department, the plan's
response will describe the actions being taken to obtain the information
or records and when receipt is expected.
(h) Nothing in this section shall preclude an enrollee from seeking
assistance directly from the Department in cases involving an imminent or
serious threat to the health of the enrollee or where the Department
determines an earlier review is warranted. In such cases, the Department
may require the plan and contracting providers to expedite the delivery of
information.
The Department may consider the failure of a plan to timely provide the
requested information as evidence in favor of the enrollee's position in
the Department's review of grievances submitted under subsection (b) of
Section 1368 of the Act.
(i)
STATE OF CALIFORNIA DEPARTMENT OF MANAGED HEALTH CARE QUARTERLY REPORT OF
PENDING AND UNRESOLVED GRIEVANCES PURSUANT TO HEALTH AND SAFETY CODE
SECTION
1368(c)
Name of Licensed Health Plan (as appearing on license):
________________________________________
DMHC Plan File No.: ___- __________
Report for _______Quarter 200 _____
Categories of Grievances Included in this Report: (Check and list current
enrollment)
[ ] Commercial [ ] Medicare [ ] Medi-Cal [ ] Healthy Families
Under Medicare and Medi-Cal law, Medicare enrollees and Medi-Cal enrollees
each have separate avenues that are not available to other enrollees.
Therefore, grievances pending and unresolved may reflect enrollees
pursuing their Medicare or Medi-Cal appeal rights.
I. Total Number of Grievances Unresolved Within 30 Days During the Quarter
Note:These include all grievances received by the plan or any entity to
which the plan has delegated grievance resolution.
Medi- Medi-
Total Comm care Cal
A. Total number of grievances pending or
submitted over 30 days at the beginning of
the quarter
_____________________________________________________________________
B. Total number of additional grievances
which exceeded the 30 days timeframe for
resolution during this quarter
_____________________________________________________________________
C. Total number of grievances that were
unresolved within 30 days at any time
during quarter (A + B)
_____________________________________________________________________
D. Total number of grievances pending
or submitted over 30 days at the end of
the quarter
_____________________________________________________________________
II. Commercial Members
Number of Commercial Member Grievances Unresolved Within 30 Days During
the
Quarter by Type of Grievance
Total, Disputes Access
all Involving to
Care
Reason Why grievan- Coverage Medical Quality (includ-
Quality
Pending ce ing of
Over 30 Days types Disputes Necessity of Care appoint-
Service
ments)
1. Pending in
Plan's
Internal
Grievance
System
_______________________________________________________________________________
2. Pending in
Department's
consumer
complaint
process
_______________________________________________________________________________
3. Pending in
Department's
Independent
Medical
Review system
_______________________________________________________________________________
4. Submitted to
Arbitration
_______________________________________________________________________________
5. Pending in
Court
_______________________________________________________________________________
6. Pending,
other dispute
resolution
_______________________________________________________________________________
Total
_______________________________________________________________________________
III. Medicare Members (complete if Medicare + Choice products provided by
Plan)
Number of Medicare Member Grievances Unresolved Within 30 Days During the
Quarter by Type of Grievance
Total, Disputes Access
all Involving to
Care
Reason Why grievan- Coverage Medical Quality (includ-
Quality
Pending ce ing of
Over 30 Days types Disputes Necessity of Care appoint-
Service
ments)
1. Pending in
Plan's
Internal
Grievance
System
_______________________________________________________________________________
2. Submitted to
Medicare
Appeals System
_______________________________________________________________________________
3. Pending in
Department's
consumer
complaint
process
_______________________________________________________________________________
4. Pending in
Department's
Independent
Medical
Review system
_______________________________________________________________________________
5. Submitted to
Arbitration
_______________________________________________________________________________
6. Pending in
Court
_______________________________________________________________________________
7. Pending other
dispute
resolution
_______________________________________________________________________________
Total
_______________________________________________________________________________
IV. Medi-Cal Members (Complete if Medi-Cal Managed Care products offered
by Plan)
Number of Medi-Cal Member Grievances Unresolved Within 30 Days During the
Quarter by Type of Grievance
Total, Disputes Access
all Involving to
Care
Reason Why grievan- Coverage Medical Quality (includ-
Quality
Pending ce ing of
Over 30 Days types Disputes Necessity of Care appoint-
Service
ments)
1. Pending in
Plan's
Internal
Grievance
System
_______________________________________________________________________________
2. Submitted to
Medi-Cal fair
hearing
process
_______________________________________________________________________________
3. Pending in
Department's
consumer
complaint
process
_______________________________________________________________________________
4. Pending in
Department's
Independent
Medical
Review system
_______________________________________________________________________________
5. Submitted to
Arbitration
_______________________________________________________________________________
6. Pending in
Court
_______________________________________________________________________________
7. Pending,
other dispute
resolution
_______________________________________________________________________________
Total
_______________________________________________________________________________
VERIFICATION
I, the undersigned, have read and signed this report and know the contents
thereof, and verify that, to the best of my knowledge and belief, the
information included in this report is true.
BY:___________________________________
(Signature of Individual Authorized to Sign on Behalf of Plan)
(Typed Name, Title, Phone)__________________
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Section 1368, Health and Safety Code.
HISTORY
1. Change without regulatory effect amending subsections (d), (f) and (g)
filed
2-23-96 pursuant to section 100, title 1, California Code of Regulations
(Register 96, No. 8).
2. Editorial correction of subsection (e) (Register 97, No. 19).
3. Amendment of section and new Notefiled 9-18-98; operative 10-18-98
(Register
98, No. 38).
4. Amendment 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.
5. Amendment 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.
6. Amendment 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.
7. Editorial correction of History5and History6 (Register 2001, No. 2).
8. 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).
9. Certificate of Compliance as to 8-14-2000 order (Regulatory Action No.
00-
0807-02E), including amendments, transmitted to OAL 11-29-2000 and filed
1-10-
2001 (Register 2001, No. 2).
10. Repealer and new section filed 11-12-2002; operative 12-12-2002
(Register
2002, No. 46).
28 CA ADC s 1300.68
END OF DOCUMENT
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