Summary:
(a) Health care service plans must provide a grievance system for enrollees. The plan must maintain a log of the grievances, including the date, name of complainant, member ID, and nature of the grievance and resolution. The plan must maintain in its files all grievances and responses for five years.
(b) After 30 days of participation in the insurance plan's grievance process, enrollees can submit their grievance to the Department of Managed Health Care for review. The department may refer any grievance that does not pertain to compliance with this chapter to the State Department of Public Health, the California Department of Aging, the federal Health Care Financing Administration, or any other appropriate governmental entity for investigation and resolution. If the subscriber or enrollee is a minor, or incompetent or incapacitated, the parent, guardian, conservator, relative, or other designee of the subscriber/enrollee, may submit the grievance to the department as the subscriber/enrollee's agent. The department must send written notice of the final disposition of the grievance to the enrollee within 30 days of receipt of the request for review, unless the director determines that additional time is reasonably necessary to fully evaluate the grievance.
(c) The plan's grievance system shall include a system of aging of grievances that are pending and unresolved for 30 days or more. The plan shall provide a quarterly report to the Director of the Department of Managed Health Care about such pending/unresolved grievances, with separate categories of grievances for Medicare enrollees and Medi-Cal enrollees. The plan shall include with the report a brief explanation of the reasons each grievance is pending and unresolved for 30 days or more.