Grievance Process

The grievance process allows the member; the member’s authorized representative, family member, etc. acting on behalf of the member; or provider acting on the member’s behalf with the member’s written consent, to file a grievance either orally or in writing. The Grievance Process is the Plan’s procedure for addressing member grievances, which are expressions of dissatisfaction about any matter other than a Notice of Action. A grievance is a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, or request for reconsideration or appeal made by a member or the member’s representative.

A member can file a grievance at any time. California Health & Wellness shall acknowledge receipt of each grievance in writing within 5 days of receipt of the grievance. Any individuals who make a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, California Health & Wellness shall ensure that the decision makers are healthcare professionals with the appropriate clinical expertise in treating the member’s condition or disease. [42 CFR § 438.406] California Health & Wellness values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf.