- Participating Physician Groups (PPG)
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 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.
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.
- Molina will generate the acknowledgement letter to Riverside and San Bernardino members but forward new cases to Health Net .
- Health Net’s case coordinator will investigate and compile the requested information but does not conduct any clinical reviews.
- The Health Net coordinator will provide a response to the Molina case coordinator via email for their review and determination for the grievance or appeal.
- When Molina closes the case they will generate the closing letter and mail it to the member. Health Net is also provided with a copy of the letter for its records.
If a member calls the Health Net call center, the representative will warm transfer the caller to Molina’s Appeal and Grievance Department to determine if a new case should be opened.
A member, or his or her physician or other representative, may file a grievance on behalf of the member anytime according to the current federal regulations, Title 42, CFR, Section 438.402(c)(i). Members may submit grievances verbally or in writing by contacting the Health Net Medi-Cal Member Appeals and Grievances Department.
Members may obtain a member grievance/complaint form from their providers' office, or they may contact the Health Net Medi-Cal Member Services Department or CalViva Health Medi-Cal Member Services Department for assistance. The Member Grievance/Complaint form for CalViva Health members is available in English, Hmong and Spanish; for other languages, members may contact the CalViva Health Medi-Cal Member Services Department for assistance. The Member Grievance/Complaint form is available in the following 12 languages for Health Net Medi-Cal members:
- Member Grievance/Complaint Form - Arabic (PDF)
- Member Grievance/Complaint Form - Armenian (PDF)
- Member Grievance/Complaint Form - Chinese (PDF)
- Member Grievance/Complaint Form Medi-Cal - English (PDF)
- Member Grievance/Complaint Form CalViva Health - English (PDF)
- Member Grievance/Complaint Form - Farsi (PDF)
- Member Grievance/Complaint Form Health Net - Hmong (PDF)
- Member Grievance/Complaint Form CalViva Health - Hmong (PDF)
- Member Grievance/Complaint Form - Khmer (PDF)
- Member Grievance/Complaint Form - Korean (PDF)
- Member Grievance/Complaint Form - Russian (PDF)
- Member Grievance/Complaint Form Health Net - Spanish (PDF)
- Member Grievance/Complaint Form CalViva Health - Spanish (PDF)
- Member Grievance/Complaint Form - Tagalog (PDF)
- Member Grievance/Complaint Form - Vietnamese (PDF)
Once the Health Net Medi-Cal Appeals and Grievances Department receives the member grievance, it is sent to a grievance coordinator for investigation. Health Net provides the member with a written acknowledgment of the grievance within five calendar days of receipt.
The member is informed in writing of the grievance resolution within 30 calendar days. If a grievance cannot be resolved within 30 calendar days, a letter of explanation that includes the reason for the delay and an estimated date of completion is sent to the member.
If the member needs help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved, or a grievance that has remained unresolved for more than 30 days, the member may call the department for assistance.
Members who have a grievance against Health Net should contact Health Net and use its grievance process. However, members may also contact the California Department of Social Services or the Department of Managed Health Care (DMHC) for assistance with a n emergency grievance or with a grievance that has not been satisfactorily resolved by Health Net.