23-752m Reminder About Timely Response to Enrollee Appeals and Grievances
Date: 07/31/23
Review enrollees’ rights, response time frames for information requests and other requirements
Enrollees have the right to file a concern about the care and services they receive from California Health & Well Plan (CHWP), its independent practice associations (IPAs), physicians and other providers.
Appeals or Grievances submitted on behalf of an enrollee must include an Authorization for Representation Form containing the enrollee’s signature and consent.
When to submit an enrollee appeal or grievance
California regulations require health plans to allow submission of an appeal or grievance within the applicable regulatory timeframes. Enrollees need to include all information from their medical identification card and the details of the concern or problem.
Receipt of an appeal or grievance
CHWP must acknowledge an enrollee’s appeal or grievance within 5 working days from the receipt date of the request. The receipt date of an appeal or grievance is the earliest stamp date, or IPA receipt date, noted on the appeal or grievance request.
Information requests
IPAs, physicians and other providers – use the table below to respond to an enrollee’s request for information.
Type of request | Requirement | Time frame to respond |
|---|---|---|
Receives enrollee appeal/grievance complaint | Forward to CHWP A&G Department. | Within one calendar day of receipt. |
Responses to routine appeals/grievances | Submit a written response, reason for the denial and all medical records to the A&G Department. | Within 5 working days of receipt. |
Responses to expedited appeals/grievances | Same day, or date indicated on the request. |
Acknowledgement and resolution letter time frames
Once an appeal or grievance is received, it is assigned a case number, researched and a decision is made.
Use the table below for the time frames to provide an acknowledgement and a resolution letter to the enrollee.
Type of request | Acknowledgement letter | Resolution letter |
|---|---|---|
CHWP A&G Regulated by DMHC or DHCS1 | Five calendar days. |
|
1DMHC – California Department of Managed Health Care or DHCS – Department of Health Care Services.
Respond timely to information requests
The IPA, physician or other provider’s written response to CHWP A&G Department’s request for information must address each of the enrollee’s issues. Medical records may accompany, but do not replace, this written response.
- Provider Information Request (PIR) form is sent by the A&G Department notifying the IPA, physician or other provider that an enrollee complaint has been received.
- IPAs, physicians and other providers must respond by sending applicable documentation by the date indicated on the PIR. Use the contact information on the form when responding to a PIR.
- All information must be complete and accurate.
Failure to respond timely
Providers who fail to respond within the indicated time frames may violate relevant portions of their Provider Participation Agreement (PPA), including Health and Safety Code section 1374.31(a), rules 1300.74.30(j) and 1300.74.30(k).
Failure to provide timely records can result in fines and penalties assessed against CHWP, IPA and physicians or other participating providers.
Questions?
If you receive an enrollee appeal or grievance in error, please fax the information to Member A&G as soon as possible at 877-831-6019.
If the information is too large to fax, please mail to:
Member A&G
P.O. Box 10348,
Van Nuys, CA 91410
Additional information
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.