§ 53858. Member Grievance Procedures.

(a) Each plan in a designated region shall establish and maintain written procedures for the submittal, processing, and resolution of all member grievances and complaints. The grievance system shall include the handling of complaints and shall:

(1) Operate according to the written procedures, which shall be approved in writing by the department prior to use. Amendments shall be approved in writing by the department prior to implementation of the revised procedure.

(2) Be described in information sent to each member within 7 days of the date of enrollment in the plan and annually thereafter, pursuant to sections 53893 and 53894. The description shall include:

(A) An explanation of the plan's system for processing and resolving grievances, and how a member is to use it.

(B) A statement that grievance forms are available in the office of each primary care provider, or in each member services department of the plan, in the case of a plan in which all primary care providers are the exclusive providers of that plan and are contiguously located.

(C) A statement that grievances may be filed in writing or verbally directly with the plan in which the member is enrolled or at any office of the plan's providers.

(D) The local or toll-free telephone number a member may call to obtain information, request grievance forms, and register a verbal grievance.

(E) A written statement explaining the member's right to request a fair hearing, provided pursuant to sections 50951, 51014.1, 51014.2, and 53894.

(F) An explanation of the state's Medi-Cal Managed Care Ombudsman program and the program's voice and TDD telephone numbers.

(b) Each plan shall make local or toll-free telephone service available to members during normal business hours for requesting grievance forms, filing verbal grievances, and requesting information.

(c) Each plan shall provide upon request a grievance form, either directly or by mail if mailing is requested to any member requesting the form.

(d) Each plan shall provide assistance to any member requesting assistance in completing the grievance form.

(e) The member grievance procedures shall at a minimum provide for:

(1) The recording in a grievance log of each grievance received by the plan, either verbally or in writing. The grievance log shall include the following information:

(A) The date and time the grievance is filed with the plan or provider.

(B) The name of the member filing the grievance.

(C) The name of the plan provider or staff person receiving the grievance.

(D) A description of the complaint or problem.

(E) A description of the action taken by the plan or provider to investigate and resolve the grievance.

(F) The proposed resolution by the plan or provider.

(G) The name of the plan provider or staff person responsible for resolving the grievance.

(H) The date of notification of the member of the proposed resolution.

(2) The immediate submittal of all medical quality of care grievances to the medical director for action.

(3) The submittal, at least quarterly, of all member grievances to the plan's quality assurance committee or review and appropriate action. For purposes of this subsection, member grievances shall include but not be limited to those related to access to care, quality of care, and denial of services.

(4) The review and analysis, on at least a quarterly basis, of all recorded grievances related to access to care, quality of care and denial of services, and take appropriate action to remedy any problems identified in such reviews.

(5) The mailing of a written notice of the proposed resolution to the member. Each notice shall include information about the member's right to request a fair hearing pursuant to sections 50951, 51014.1, 51014.2, and 53894.

(6) A system for addressing any cultural or linguistic requirements related to the processing of member grievances prescribed in the contract between the plan and the department.

(7) A procedure for the expedited review and disposition of grievances in the event of a serious or imminent health threat to a member, in accordance with Health and Safety Code section 1368 and 1368.02.

(f) Grievance forms shall be available in the offices of each of the plan's primary care providers, or in each member services department of the plan, in the case of a plan in which all primary care providers are the exclusive providers of that plan and are contiguously located.

(g) Each plan shall adhere to the following requirements and time frames in processing member grievances:

(1) Member grievances shall be resolved within thirty days of the member's submittal of a written grievance or if the grievance is made verbally, it shall be resolved within 30 days of the written record of the grievance.

(2) In the event resolution is not reached within thirty days, the member shall be notified in writing by the plan of the status of the grievance and shall be provided with an estimated completion date of resolution.

(3) Such notice shall include a statement notifying the member they may exercise their right to request a fair hearing in accordance with sections 50951, 51014.1, 51014.2, and 53894.

(h) Each plan shall maintain in its files copies of all grievances, the responses to them, and logs recording them for a period of five years from the date the grievance was filed.

(i) Any member whose grievance is resolved or unresolved shall have the right to request a fair hearing. Submission of a grievance shall not be construed as a waiver of the member's right to request a fair hearing in accordance with sections 50951, 51014.1, 51014.2, and 53894.

HISTORY

1. New section filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

2. Repealer of section and Note and new section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

Note

Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 10950 through 10965, 14087.3, 14087.4 and 14450, Welfare and Institutions Code.