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.
The member will be allowed 90 to 180 calendar days from the date of the incident to file a grievance. 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.
Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the member’s health condition requires, not exceeding 30 calendar days from the date of the initial receipt of the grievance. California Health & Wellness may extend the timeframe for disposition of a grievance for up to 14 calendar days if the member requests the extension or the Plan demonstrates that there is need for additional information and how the delay is in the member’s interest. The Plan will provide written notice to the member if the timeframe is extended by the Plan, along with a reason for the delay.
Expedited grievance reviews will be available for members in situations deemed urgent, such as a denial of an expedited appeal request, and will be resolved within 72 hours. Consideration of the member’s medical condition is taken into consideration when determining response time. The member has the right to contact the DHCS for any urgent grievance, no matter if they have not exhausted the Plan’s grievance process.
An appeal is a request for review of a previous decision of the Plan including a grievance determination or a “Notice of Action.” A “Notice of Action” is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the California Health & Wellness network.
Appeals may be filed orally or in writing by the member or a provider acting on behalf of the member. An appeal must be filed within 90 calendar days from the date on the notice of action or resolution or within 10 calendar days if the member is requesting to continue benefits during the appeal investigation. Standard appeals must be resolved within 30 calendar days of receipt of the appeal, with a 14 day extension possible if additional information is required. Members may request that California Health & Wellness review the Notice of Adverse Action to verify if the right decision has been made.
Expedited appeals may be requested if the member requests or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking the time for a standard resolution could seriously jeopardize the member’s life, health or ability to attain, maintain, or regain maximum function.
Expedited appeals requested orally do not require subsequent written request. Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. California Health & Wellness may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if California Health & Wellness provides evidence satisfactory to the DHH that a delay in rendering the decision is in the member’s interest. For any extension not requested by the member, California Health & Wellness shall provide written notice to the member of the reason for the delay. California Health & Wellness shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.
No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.
State Fair & Expedited State Fair Hearing Process
A member, their representative or provider may request a State Fair Hearing at any time during the Grievance or Appeal process. Requests for State Fair Hearing must be submitted within 90 calendar days from the date of the notice of action regarding their expedited or standard appeal. If the member wishes to have continuation of benefits during the State Fair Hearing, the request must be submitted within 10 calendar days.
Expedited State Fair Hearing Process
This expedited process only applies for a Plan denial of a requested service and if the issue involves imminent and serious threat to the member’s health. Decision is made within 72 hours.
Independent Medical Review
Members may request an independent medical review (IMR) for decisions that the Plan denied due to its determination the therapy or medical service denied is experimental or investigational. Members who have presented the disputed health care service for resolution by the Fair Hearing process are not eligible for an IMR. Contact California Health & Wellness to obtain the form “Independent Medical Review Application” to request an IMR through the DHCS. The request for an IMR must be filed with the DHCS within six months of the plan’s written response to the member’s grievance. The DHCS will notify the member and the Plan if an application for IMR has been accepted within seven calendar days of receipt of a routine request and within 48 hours for an expedited review
The DHCS will review the information submitted and determine whether the member is eligible for an IMR. The determination will use all information received and the member’s medical condition and the disputed health care service when making the determination. Each assigned review will issue a separate written analysis of the case, explaining:
- the determination made,
- how the determination relates to the member’s medical condition and history, medical records, etc., references to the specific medical and scientific evidence as applicable, and
- may also include the risks and benefits considered.