Grievances

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

A provider grievance is an oral or written expression of dissatisfaction or concern that does not involve a prior determination. Provider grievances include quality of care concerns, access to care concerns, complaints regarding delays of referrals or authorizations, patient dumping issues, and provider refusals to submit medical records. There are two types of provider grievances:

  • administrative - concerns of a non-clinical nature
  • clinical - concerns of a clinical nature

Provider grievances may be submitted orally or in writing within 180 days of the date of occurrence. The first step in registering a grievance is to call the Health Net Medi-Cal Provider Services Center, Community Health Plan of Imperial Valley Provider Services Center or CalViva Health Medi-Cal Provider Services Center (for Fresno, Kings and Madera counties).

The second step is to submit it in writing with the following information:

  • a description of the problem, including all relevant facts
  • names of involved people
  • date of occurrence
  • supporting documentation

Health Net participating providers are notified in writing of receipt of a grievance within five business days. A grievance received without all required information is returned to the submitting provider with instructions for resubmitting the grievance with the missing information. The provider must resubmit the completed grievance within 30 business days of receipt of the request for additional information.

Providers are informed in writing of resolution of the grievance within 30 business days. If resolution of the case exceeds 30 business days, Health Net will send the provider a letter of explanation by the 30th business day, documenting the reason for the delay and an estimated completion date for the resolution.

Resolution Process

A Health Net Medi-Cal Provider Services representative who receives the grievance forwards the information to a Health Net Medical Review Unit case coordinator. The case coordinator handles the grievance and corresponds with the provider, including requesting any additional information necessary. Upon receipt of all necessary information, the case coordinator forwards the grievance to the Health Net regional medical director responsible for the region for review and resolution of the grievance.

The Health Net regional medical director reviews all provider grievances. The medical director evaluates the grievance using multiple resources, criteria and guideline sets that include:

  • Title 22, California Code of Regulations.
  • Electronic Data Systems (EDS) Medi-Cal Provider Manual guidelines.
  • Department of Health Care Services (DHCS) Manual of Criteria.
  • Current Procedural Terminology (CPT) guidelines.
  • InterQual Criteria sets (McKesson).
  • Hospital Chargemaster Guide (Ingenix).
  • Health Net Medi-Cal claims policies and procedures.

Upon completion of the medical director review and determination, the case is returned to the case coordinator who then notifies the provider in writing of the determination, the reason for the determination, actions taken, and a description of the provider's options if the provider is dissatisfied with the outcome.

Information gathered by Health Net, and as a result of the review of quality-related grievances that involve a provider, is considered confidential and protected from disclosure as quality of care-related peer review activities under California law. Provider grievances related to a request for reassignment or disenrollment of a Medi-Cal member are referred to the Health Net Medi-Cal Member Services Department.