Update in Grievance Process – Grievances and Grievance Replies
| Date: | May 16, 2019 |
| To: | Health Plan of San Joaquin (HPSJ) Primary Care Providers (PCP) |
| From: | HPSJ Quality Management Department |
| Subject: | Update in Grievance Process – Grievances and Grievance Replies |
| Business: | Medi-Cal |
Health Plan of San Joaquin (HPSJ) is charged with maintaining quality of care for our members and as such must investigate, or follow through, regarding concerns of medical care or delivery of care.
The HPSJ Quality Management (QM) Department is tasked with monitoring and investigating member complaints, also known as grievances, in a timely manner by both the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC). Members have the right to file complaints with either HPSJ or DHCS/DMHC for investigation and resolution.
Following is the grievance process we follow:
1. HPSJ’s QM Department will send formal grievance letters by fax, encrypted email, or by certified mail if no other option exists.
2. On rare occasions, an HPSJ Provider Services Representative may deliver the grievance letter, as well, if other options fail.
3. The standard allowance for reply from providers is 5 business days of receipt.
4. Please ensure that your staff are aware to contact HPSJ’s QM Department if more time is required to internally investigate and prepare a response.
5. Failure on the part of the provider to respond to the grievance may result in the case being closed in member’s favor without further action. Also, a CAP (corrective action plan) can be issued based on the severity of the case, at the discretion of the HPSJ Medical Director.
Definitions-
A Grievance is a written or oral expression of dissatisfaction regarding the Plan or Provider, about any matter other than an Adverse Benefit Determination.
- Grievances may include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, and the beneficiary’s right to dispute an extension of time proposed by the MCP to make an authorization decision.
- A complaint is the same as a Grievance. When the Medi-Cal Plan is unable to distinguish between a Grievance and an inquiry, it shall be considered a Grievance.
- An inquiry is a request for information that does not include an expression of dissatisfaction.
- Inquiries may include, but are not limited to, questions pertaining to eligibility, benefits, or other MCP processes.
Resolution means that the Grievance has reached a final conclusion with respect to the submitted complaint.
- Grievances must be resolved within 30 days unless marked as urgent/expedited, which require resolution within 72 hours of receipt of complaint.
- Members and/or DHCS or DMHC must be notified in writing of the resolution of the complaint.
- Urgent/Expedited Grievances– requires immediate response from the Plan and provider(s) involved (within 24 hours of DMHC notification). Must be resolved within 72 hours of the initial complaint.
- Standard Grievances – requires response from the Plan and provider(s) involved within 3 days of DMHC notification. Must be resolved within 30 days.
Please note for member complaints forwarded by DMHC:
HPSJ has an obligation to members to ensure that highest level of quality care is rendered by participating providers. HPSJ monitors this activity, and advises and works collaboratively with providers to identify areas of opportunity for efficient responses that will help enhance quality care for members.
Thank you very much for being our partner in our commitment to provide safe and quality care to our members, your HPSJ patients.
If you have any questions, please contact our Quality Management Department at 209.942.6325; Monday – Friday 8:00AM to 5:00PM.