Important Information: Grievances and Grievance Replies
| Date: | July 6, 2018 |
| To: | All Health Plan of San Joaquin (HPSJ) Contracted Providers, Facilities, and Ancillary Services |
| From: | HPSJ Quality Management Department |
| Subject: | Important Information: Grievances and Grievance Replies |
| Business: | Medi-Cal |
Health Plan of San Joaquin (HPSJ) is charged with maintaining the quality of care for our members and as such must investigate or follow through regarding any member concerns about their medical care or delivery of care.
The HPSJ Quality Management (QM) Department is tasked by the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC) with monitoring and investigating member complaints, also known as grievances, in a timely manner. Members have the right to file complaints with either HPSJ or DHCS or DMHC for investigation and resolution.
Definitions
- A Grievance is a written or oral expression of dissatisfaction regarding the MCP (Managed Care Plan; a.k.a. Health Plan of San Joaquin) or Provider, about any matter other than an Adverse Benefit Determination.
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- 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 MCP is unable to distinguish between a Grievance and an inquiry, it shall be considered a Grievance.
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- 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. Grievances and Grievance Replies
- 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.
The Process
- HPSJ’s QM Department will send formal grievance letters by fax, encrypted email, or by certified mail if no other option exists.
- On rare occasions, an HPSJ Provider Services Representative may deliver the grievance letter if other delivery options fail.
- The standard allowance for reply from providers is five (5) business days after receipt of the grievance letter.
- Please ensure your staff are aware they must contact HPSJ’s QM Department if more time is required to internally investigate and prepare a response. Failure to reply timely can result in a negative determination against your practice/facility and can result in disciplinary action.
Please note for member complaints forwarded by DMHC:
- Urgent/Expedited Grievances – require 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 – require response from the Plan and provider(s) involved within 3 days of DMHC notification. Must be resolved within 30 days.
HPSJ has an obligation towards our members to ensure that the highest level of quality care is rendered by participating providers. HPSJ monitors this activity, advises and works collaboratively with providers regarding the areas of opportunity.
Thank you very much for being our partner in our commitment to provide safe and quality care to our members. If you have any questions, please contact our Quality Management Department at 209.942.6325; Monday – Friday, 8:00AM to 5:00PM.