SFHP POLICY AND PROCEDURE Member Grievances and Appeals

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1 SFHP POLICY AND PROCEDURE Member Grievances and Appeals POLICY STATEMENT San Francisco Health Plan (SFHP) encourages its members or the member s representative to voice their dissatisfaction with SFHP s and/or its providers services through the Grievances and Appeals process. The SFHP grievance process is designed to address and resolve members concerns in a manner that is timely, fair, and thorough. SCOPE PROCEDURE The basic grievance process described in this policy and procedure is available to all SFHP members. This policy also includes specific processes that are available only to Medi-Cal beneficiaries. Additional policies govern SFHP s utilization management process, including the process for initially denying, delaying, or modifying health care services. The grievance process is used when a member or the member s representative elects to dispute a utilization management decision, or to express any other form of dissatisfaction with the services provided by SFHP or its providers. Member Rights 1. A member has the right to file a grievance for any reason. Members can file a grievance that is not about a Notice of Action (NOA) within one hundred and eighty (180) days from the date the incident or action occurred which caused the member to be dissatisfied. If a member is dissatisfied with an NOA, the member has ninety (90) days from the date of the NOA to file an appeal. 2. SFHP does not discriminate against a member, or disenroll a member because he/she filed a grievance. 3. A member has a right to continuous medical care. A SFHP provider cannot withhold or terminate care because a member has filed a grievance. 1 P age

2 4. A member has the right to have a representative, advocate and/or lawyer assist in the grievance process. 5. A member has the right to language translation during any part of the grievance process. Standard documents and correspondence are available in threshold languages. SFHP s policy, Use of Interpreter Service and Bilingual Staff and Translation of Member Materials, details SFHP s system for addressing cultural and linguistic requirements. 6. A member has the right to propose a solution to a grievance. 7. A member has the right to be informed, by SFHP, of the limited time available to present evidence in support of an appeal; in addition, if requested by the member, SFHP must provide records in connection with a grievance. Cultural and Linguistic Requirements The CS Grievance Coordinator and the QI Coordinator are trained by the Project Manager of Health Education and Cultural and Linguistic Services. This procedure ensures that all grievances are reviewed by the Customer Service (CS) or Quality Improvement (QI) Grievance Coordinators for any cultural and linguistic issues. These policies ensure that the grievance process is accessible and fair to all members. Identification, Documentation and Tracking/Trending Disability Components of Member Grievances SFHP is committed to identifying and reporting on member grievances that have a disability component to them. All grievances are reviewed by the Customer Service and Clinical Quality Coordinators for Disability Components. The coordinators are responsible for identifying grievances with a disability component in the grievance log. Member Information SFHP assists its members in understanding and using all internal and external grievance and appeal processes available to them. It provides all members access to comprehensive, accurate and easily understood information about the grievance and appeals procedure. The procedure is published in the Member Handbook. At minimum, the following information is included: 1. How to file a grievance, by phone or in person, verbally or in writing, by contacting the primary care practitioner s office, the medical group or SFHP. 2. How to appeal a grievance determination. 3. How to contact the SFHP Customer Service Department for assistance in the grievance process, to find an independent advocate, to access translation services or for any other reason. 4. How to request an expedited medical review. 2 P age

3 5. How to contact the DMHC, using the toll-free telephone number, the telephone number for relay services provided for the hearing and speech-impaired, and the website (A separate SFHP policy governs independent medical review). 6. For Medi-Cal beneficiaries: how to request a State Fair Hearing and how to reach the Ombudsman, using toll-free and TDD phone numbers. Provider Information SFHP informs its providers about grievance and appeal procedures through the Provider Operations Manual and through regular trainings and audits. SFHP distributes Grievance Intake Forms (attached) in the required threshold languages to all primary care and medical group offices. SFHP Customer Service Department The SFHP Health Improvement Department is responsible for coordinating and processing all clinical grievances. The SFHP Customer Service Department is responsible for coordinating and processing all non-clinical member grievances. Whenever any issue arises that is, in any part, an expression of dissatisfaction, any SFHP staff will complete a Grievance Intake form (attached) and forward it to the Clinical Quality Coordinator. The intake form documents that a grievance has been voiced and needs resolution through the grievance process. An issue that is an imminent and serious threat to health is brought to the immediate attention of the SFHP Chief Medical Officer (CMO). The intake form includes a description of the problem, a summary of what the member would like done to resolve the grievance, what the member has been told by the SFHP staff, and information about how to reach the member. The Customer Service Department refers members with grievances involving carved out services to the appropriate agency. How a Member Files a Grievance The SFHP Customer Service Department ensures that members have the opportunity to fully express a grievance. 1. Members or their representatives may file a grievance with the SFHP Customer Service Department by phone, mail, fax, , in person, or through our website. 2. The medical group staff and providers may refer the member to the SFHP Customer Service Department and/or directly assist the member to file a grievance by phone. 3. The member and/or the member s representative may complete a SFHP Grievance Form and submit it to the SFHP Customer Service Department. Grievance Forms are available in threshold languages through the SFHP Customer Service 3 P age

4 Department (by mail, fax, , in person, or on our website) and in all primary care and medical group offices. A member s signature is not required. 4. Upon intake, per the Code of Federal Regulations, members, or their representative, are informed that they may at any time during the appeals process review all documents associated with the grievance case, including medical records. Members are also informed that they have the right to submit additional evidence in support of their grievance. 5. If a member or a member s representative calls the SFHP Customer Service Department with an inquiry or otherwise expresses dissatisfaction regarding the plan and/or provider, but the Customer Service Representative is not able to distinguish whether the member has an inquiry or a grievance, the call shall be considered a grievance. In such cases, the procedures outlined for member communication and documentation regarding grievances outlined below shall be followed. Decline to File a Grievance If a member or his/her representative calls the SFHP Customer Service Department with an inquiry or otherwise expresses dissatisfaction regarding the plan and/or provider, but states that he/she does not want to file a grievance, the SFHP Customer Service Representative will do the following: Confirm with the member or his/her representative that he/she does not want to file a grievance. Send the member a Decline to File Grievance letter that states the member s call was received, the issue was reviewed and discussed, but the member does not want to file a grievance. Save a copy of the Decline to File Grievance letter sent to the member in the Customer Service Department folders. Log the call in the SFHP managed care system (QNXT). Timeframes for Member Grievances If a member receives a Notice of Action (NOA) from San Francisco Health Plan, the member has three options. (A Notice of Action is a formal letter telling the member that a medical service has been denied, deferred, or modified.) Members have ninety (90) days from the date on the Notice of Action to file an appeal of the Notice of Action with San Francisco Health Plan Members may request a State Hearing regarding the Notice of Action from the Department of Social Services (DSS) within ninety (90) days. Members may request an Independent Medical Review (IMR) regarding the Notice of Action from the Department of Managed Health Care (DMHC). 4 P age

5 Members may file an appeal with San Francisco Health Plan regarding a Notice of Action and request a State Hearing regarding that Notice of Action at the same time. However, an IMR may not be requested if a State Hearing has already been requested for that Notice of Action. Members can also file a grievance that is not about a Notice of Action. Members must file a grievance within one hundred and eighty (180) days from the date the incident or action which caused the member to be dissatisfied. Clinical and Non-Clinical Grievances All grievances are reviewed by the Medical Management Nurse to determine whether the grievance may be clinical or non-clinical. If the grievance is clinical in nature, the Medical Management Nurse works with the Clinical Quality Coordinator to investigate and process the grievance. Also, the Medical Management Nurse will review the grievance for any possible Potential Quality Issue (PQI). If there is a possible PQI, the Medical Management Nurse will notify the CMO or Physician Designee. The CMO or Physician Designee reviews all clinical grievances prior to resolution. The CMO or Physician Designee reviews and signs all clinical grievance resolution letters. If the grievance is non-clinical the Medical Management Nurse forwards the grievance to the Customer Service Grievance Coordinator for processing and resolution. To ensure the appropriate initial classifying of grievances between clinical and non-clinical grievances, internal monitoring by inter-rater reliability will be conducted on a quarterly basis. Each quarter, a random selection of 10 cases will be selected for review. The 10 cases will be blinded and the CMO will review the cases and assign clinical or non-clinical classifications to each case. A 90% inter-rater reliability is desired. Every grievance is resolved as expeditiously as the member s health condition requires. An issue that is an imminent and serious threat to health is brought to the immediate attention of the CMO. The SFHP CMO determines if a grievance qualifies for expedited review and investigates the issue through discussion with the involved practitioners, medical record review or other means. The CMO establishes an appropriate procedure and timeline. Appropriate issues to refer to clinical staff include: 1. Delay of a requested health care service 2. Modification or denial of a requested health care services 3. Patient disagrees with provider's treatment 4. Patient disagrees with diagnosis 5. Alleged failure or refusal by a practitioner to refer 6. Unavailability of practitioner (during and after-office hours) 7. Practitioner does not provide alleged covered and medically necessary service 5 P age

6 8. Alleged adverse results of treatment 9. Alleged refusal or delay in providing services or treatment 10. Alleged inappropriate practitioner behavior 11. Other issues that are judged to be clinical in nature Grievance Process 1. The SFHP Customer Service and Clinical Quality Coordinators are available to assist the member throughout the grievance process. 2. The Clinical Quality Coordinator will log and track all grievances in the grievance log. 3. Grievances received over the telephone that are not coverage disputes, disputed health care services involving medical necessity or experimental or investigational treatment, and that are resolved by the close of the next business day, are exempt from the requirement to send a written acknowledgement and response. These grievances are still entered in the log. 4. Except as described in #3 above, a written acknowledgement letter is provided within five calendar days of receipt (Refer to definition section for Turn Around Time). This acknowledgement advises the member that the grievance has been received, the date of the receipt, and provides the name, telephone number and address of the SFHP Customer Service Grievance Coordinator for non-clinical grievances and the SFHP Clinical Quality Coordinator for clinical grievances. The letter, at minimum, contains all the components and information included in the acknowledgement letter template attached to this policy. 5. The SFHP Customer Service Grievance Coordinator forwards all grievances to the Medical Management Nurse for review. The Medical Management Nurse makes the determination of whether a grievance is clinical or non-clinical. 6. If the grievance is clinical, the Clinical Quality Coordinator works with the Medical Management Nurse to investigate and process the grievance for review and final determination by the Chief Medical Director (CMO) and/or Physician Designee. See section on Clinical versus Non-Clinical Grievances below for additional detail. For non-clinical grievances, the Customer Service Coordinator collects necessary information for resolving the complaint, which is reviewed by the Customer Service Senior Manager. 7. Both the Clinical Quality Coordinator and the Customer Service coordinator are responsible for screening grievances for cultural and linguistic issues and disability componets. They are trained by the Health Education and Cultural and Linguistic Services Project Manager. The Project Manager of Health Education and Cultural and Linguistic Services will also perform annual oversight audits of grievances to ensure that cultural and linguistic issues are being identified, logged, and appropriately addressed. 8. The Grievance Coordinators consult as needed with other staff responsible for the areas of service that are subject to the grievance. 6 P age

7 9. The Customer Service Grievance Coordinator (non-clinical grievances) and the Clinical Quality Coordinator (clinical grievances) will review for and document any grievance that has a disability component on the grievance log and in their resolution, as appropriate. 10. The person who filed the grievance is contacted and given the opportunity to present evidence, facts, and law in support of their grievance. 11. The CMO and/or Physician Designee review all clinical grievances, determine whether a potential quality issue (PQI) is present, and documents case findings on the Medical Director Review Form (MDRF). The CMO and/or Physician Designee records the date of the review, any potential quality issues, and instructions for follow-up on the MDRF. 12. All reviewing parties should be documented in the grievance file and noted (especially the physician who made the initial denial) to ensure a fair and thorough reassessment by the appropriate reviewers. 13. The Customer Service Senior Manager reviews all non-clinical grievance resolution letters prior to mailing. 14. For non-clinical grievances, the Customer Service Grievance Coordinator processes and resolves the complaint, under the supervision of the Customer Service Senior Manager. 15. For clinical grievances, the Clinical Quality Coordinator mails the clinical grievance resolution letter to the member within 30 calendar days of receipt, except as described in #3 above. For non-clinical grievances, the Customer Service Grievance Coordinator mails the grievance resolution letter to the member within 30 calendar days of receipt, except as described in #3 above. The written response contains a clear and concise explanation of SFHP s decision. The letter also contains all the components and information included in the resolution letter templates attached to this policy. The resolution letter is timed to allow sufficient time for an appeal, if the member requests it, within the 30 day time period. 16. For grievances involving a denial for medical services, the Clinical Quality Coordinator includes an IMR form to the DMHC and a return envelope. 17. Medi-Cal members have ninety (90) days from the date on the Notice of Action to file an appeal of the Notice of Action with San Francisco Health Plan. They may request a State Hearing regarding the Notice of Action from the Department of Social Services (DSS) within ninety (90) days from the date on the Notice of Action at the same time the appeal is filed with the San Francisco Health Plan. However, an IMR may not be requested if a State Hearing has already been requested for that Notice of Action. 18. For clinical grievances and denial appeals, the Clinical Quality Coordinator and the Medical Management clinical staff investigate and processes the grievance and ensures that the CMO or Physician Designee, reviews and resolves the grievance or appeal prior to the issuance of the resolution letter. The CMO or Physician Designee, reviews and signs all clinical grievance resolution letters. 19. The resolution letter is sent to the member on the date the CMO or Physician Designee, signs and dates the letter. 7 P age

8 20. The Customer Service and Clinical Quality Coordinators are responsible for completing the grievance log when a grievance or appeal is closed. The Clinical Quality Coordinator is responsible for compiling data for the Quality Improvement Committee. 21. SFHP adheres to the requirements and timeframes in processing member grievances. In the event resolution is not reached within 30 days, the member shall be notified in writing by SFHP of the status of the grievance and shall be provided with an estimated completed date of resolution. 22. SFHP, medical group staff and committee members who assist in the grievance process agree to strict standards of confidentiality. 23. SFHP stores all grievance files and logs electronically in SFHP SharePoint secure system, and stores hard copies in a secure location for at least seven years from the date of its creation or the date when the service occurred, whichever is later (Privacy Rule). Books and records related to Medi-Cal shall be maintained for a minimum of five years from the termination of the Contract with the Department of Health Care Services (DHCS). Grievances of Disputed Health Care services (Denial Member Appeals) 1. The member has ninety (90) days from the date of the NOA to file an appeal. If the member is not satisfied with the appeal decision, the member is given instructions for initiating an appeal through the State Fair Hearing Process. 2. The Clinical Quality Coordinator sends the member an acknowledgement letter. The letter, at minimum, contains all the components and information included in the acknowledgement letter template attached to this policy. 3. The SFHP CMO or Medical Designee reviews the initial decision to deny, defer or modify care and may overturn it. 4. If the initial decision is not overturned, the CMO sends the grievance to an outside medical reviewer appropriately qualified to review the medical issue for a final decision. The outside final reviewer may overturn or uphold the initial decision. 5. The CMO reviews and signs all clinical grievance resolution letters. The resolution letter is sent to the member by the Clinical Quality Coordinator. 6. If the member accepts the resolution, the case is closed. 7. Cases originally denied by the Associate Medical Director or Physician Designee will be subsequently reviewed, and may be overturned, by the CMO. Appeals that are addressed by the Member Grievance Process include disputes that are regarding denials of pharmaceuticals or clinical services that were requested, but had not yet occurred. Appeals that are addressed by the Provider Dispute Resolution Process (see CL-07) are regarding the denial of a claim or the denial of a service that has been rendered. Appeals that are not on behalf of the member will be addressed through the Provider Appeals process (see UM-49). SFHP may utilize the right to verify if an appeal has truly been made on behalf of the member. 8 P age

9 Expedited Review When grievances of disputed health care services involve a serious and imminent threat to the health of the member, the grievance process is expedited, and the clinical status of the patient is monitored throughout the process and acts as expeditiously as the member s health requires. The total time permitted for an expedited review is threecalendar days. {A Medi-Cal member may bypass SFHP s grievance process and apply for an expedited State Fair Hearing. The member may also file for an expedited State Fair Hearing concurrently with using the SFHP grievance process. If SFHP fails to resolve an expedited issue in 72 hours or its resolution is wholly or partially adverse, the member may also file. SFHP or the member s provider will provide documentation supporting the need for an expedited hearing. SFHP responds within two business days to requests for documents pertinent to the expedited hearing and assigns a representative to participate.} 1. The Clinical Quality Coordinator informs the member of his/her right to concurrently notify the DMHC about the grievance, and provides the member with all information contained in the notice for Filing a Grievance with the DMHC. The initial notification need not be in writing and can be accomplished by a documented telephone call. The Clinical Quality Coordinator also mails an acknowledgement letter that contains all the components and information included in the acknowledgement letter template attached to this policy. 2. The Clinical Quality Coordinator updates the grievance log to indicate an expedited review, and documents the date and time of each action taken. 3. The expedited review is initiated immediately upon receipt, and is resolved no later than three calendar days. The member and provider are informed of the resolution immediately, by phone or fax, and a written resolution letter follows. 4. The Clinical Quality Coordinator sends a resolution letter regarding the disposition or status of the grievance no later than three-calendar days after the grievance is filed. The letter is sent to the member and the practitioner. The letter, at minimum, contains all the components and information contained in the disputed health care services resolution letter template attached to this policy. Grievance Log The Clinical Quality Coordinator logs member grievances in the grievance database, which is used for generation, aggregation and tabulation of grievances. The grievance log records at minimum the following information: 1. The date and time the grievance is filed 2. The name of the member filing the grievance and the person representing the member 9 P age

10 3. The name of the staff person receiving the grievance 4. A description of the grievance 5. A code for tracking the grievance by category (attached) 6. Information regarding physical or language requirements that are relevant to ongoing communication with the member or the member s representative 7. Designation that the grievance has a cultural and/or linguistic component 8. Designation that the grievance has a disability component 9. A description of all actions taken to investigate and resolve the grievance and the dates the actions were taken 10. The proposed resolution 11. The date that the member is notified of the proposed resolution 12. A dated record of all member contacts 13. The name of the person responsible for resolving the grievance 14. The date that the issue is resolved Pended and Unresolved Grievances SFHP makes every effort to resolve grievances within the required timeframe, but for grievances that are pended or unresolved for 30 calendar days or more, SFHP would continue to work towards a grievance resolution and highlight that it had exceeded the 30-day timeframe in the Grievance Log. SFHP would report any grievances that are pending or unresolved for 30 calendar days or more to DMHC and DHCS on a quarterly basis through the quarterly grievance reports. Grievance File The Quality Improvement and Customer Service Grievance Coordinators maintain a grievance file that contains all evidence collected while investigating the grievance, including medical records, evidence of coverage and other documents relevant to the grievance determination, and copies of all correspondence. Filing a Grievance with the DMHC A SFHP member may file a grievance with the DMHC after completing SFHP s process or after 30 calendar days have elapsed since the grievance was filed. An earlier review may be allowed in expedited situations. For grievances pertaining to dissatisfaction with a Notice of Action, an IMR may not be requested if a State Hearing has already been requested for that Notice of Action. 10 P age

11 1. SFHP includes the following language in all correspondence related to the grievance and appeal process and in SFHP s Member Handbook: "The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1 (800) or (415) and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line ( ) for the hearing and speech impaired. The department's Internet Web site has complaint forms, IMR application forms and instructions online." 2. When SFHP receives notification that a member has filed a grievance with the DMHC, it submits a response and copies of relevant documents from the SFHP grievance file, including all related medical records and the applicable evidence of coverage within five-business days of the request. 3. Upon receipt of a DMHC grievance determination, SFHP acts to implement the decision within the deadlines set by the DMHC. State Ombudsman Office SFHP informs Medi-Cal beneficiaries in their Handbook, and in all correspondence regarding the grievance and appeal process that they may call the State Ombudsman for help with a grievance. The Ombudsman Office is reached toll-free at The TDD number is Its office hours are Monday-Friday, 8 am to 5 pm, closed on State holidays. State Fair Hearing SFHP informs Medi-Cal beneficiaries in their Member Handbook and in all correspondence regarding the grievance and appeal process that, in addition to the SFHP grievance process, they may request a State Fair Hearing. For grievances pertaining to dissatisfaction with a Notice of Action, members may request a State Hearing regarding the notice of Action from the Department of Social Services (DSS) within ninety (90) days from the date on the Notice of Action. Members may file an 11 P age

12 appeal with San Francisco Health Plan regarding a Notice of Action and request a State Hearing regarding that Notice of Action at the same time. 1. The member or the member s representative is informed that: Information regarding the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box , MS 19-37, Sacramento, CA, , or by calling The TDD number is Requests for a State Fair Hearing can be made one of the following ways: o To the county welfare department at the address shown on the Notice of Action. o To the California Department of Social Services, State Hearings Division, P.O. Box , Mail Station 19-37, Sacramento, California o To the State Hearings Division California Department of Social Services Public Inquiry and Response Phone (Voice) (TDD) Fax (916) The member or the member s representative may chose to be represented by a friend, an attorney, or another person at the State Fair Hearing. To find out about free legal assistance, the member may call the toll-free number of Public Inquiry and Response Unit at The member or the member s representative may call the State Ombudsman for help. The Ombudsman Office is reached toll-free at The TDD number is , Monday-Friday. Its hours are 8 a.m. to 5 p.m., closed on State holidays. The member or the member s representative must request the hearing within 90 days of an action to delay, defer or modify health care services. When a member files for a hearing within 10 days of a notice to delay, modify or deny medical services, current services will be authorized until a State Fair Hearing decision is made. The member or the member s representative may examine the materials that make up the record for the State Fair Hearing decision, and may locate the record by contacting the Public Inquiry and Response Unit at Any information that the member provides for a hearing may be shared with the county Department of Social Services or with the United States Department of Health and Human Services. 12 P age

13 2. When SFHP receives notification that a member has requested a State Fair Hearing, it prepares a position statement. A copy of the position statement is sent to the member, to the Department of Health Care Services MMCD Ombudsman Unit PO Box , MS 4412, Sacramento, CA ; and to CDSS, State Hearing Division, PO Box , MS19-37, Sacramento, CA SFHP submits its position statement at least five-business days prior to the date of the hearing. 3. When a finding on the final disposition of the case is received from the State Fair Hearing Officer, SFHP acts to implement the order within the deadlines set by the order. If the issue is a medical service, it is authorized within five business days or sooner if medically indicated. If the service has already been rendered, any outstanding claims are reimbursed within five business days. The Medical Group s Role 1. SFHP relies on its medical groups to encourage SFHP members to express any service dissatisfaction directly to SFHP and to work with SFHP to resolve grievances as quickly and as fairly as possible. 2. Medical groups and primary care providers must know how to assist members in the SFHP grievance process and have SFHP Grievance Forms available. 3. When a member expresses any form of dissatisfaction, the medical group staff and providers must give the member a SFHP Grievance Form, and offer assistance to submit it. They may also advise the member to contact SFHP's Customer Service Department by any method. They may directly assist the member to file a grievance with the SFHP Customer Service Department by phone. 4. Medical groups and providers must also assist in the review and resolution of member grievances. This process includes retrieving medical records and providing any other information necessary to resolve the grievance. 5. The medical group assures that the member receives continuous medical care during the grievance process. 6. Medical groups and providers must take corrective action as determined by a member grievance resolution, and also address systemic issues identified in the grievance process. Delegation 1. SFHP delegates the grievance process to one medical group, Kaiser Health Plan. 2. SFHP oversees the delegation of the grievance process that is conducted by Kaiser Health Plan through quarterly reviews of Kaiser s grievance log and annual audits. 3. SFHP requires corrective action whenever it identifies a problem in Kaiser Health Plan s grievance process, and assigns a deadline for receiving evidence that the 13 P age

14 problem has been resolved. For serious or persistent problems, SFHP may require that Kaiser Health Plan refer all member grievances directly to SFHP for resolution. Quality Improvement Committee Oversight 1. The SFHP Governing Board oversees the grievance process. The SFHP Director of Health Improvement is responsible for maintaining grievance procedures, reviewing the operation of the process, and leading SFHP s quality committees in identifying emergent patterns of grievances in order to initiate systemic improvements in SFHP operations. 2. The SFHP quarterly grievance report identifies grievances by category. The report will include grievances that have a cultural and linguistic or disability component, so they can be tracked and trended. 3. SFHP quality improvement committees assure that grievances and appeals are addressed in a manner that is accessible, timely and thorough. The quality improvement process is used to examine individual grievances and grievance trends in order to establish priorities for improvement and to implement appropriate improvement actions. The Clinical Quality Coordinator oversees the maintenance of the grievance log and the preparations of grievance reports. The report highlights grievance trends by category, line of business and medical group. It identifies all grievances that have not been resolved within specified time frames. The Quality Improvement Committee reviews quarterly grievance reports. It may act to improve the quality and efficiency of the process, or to initiate improvement activities that directly address the issues raised. The Quality Improvement Committee reviews trended grievance information, and receives reports from the Clinical Quality Coordinator. It may act to improve the quality and efficiency of the process, or to initiate improvement activities that directly address the individual or systemic issues raised. The Quality Improvement Committee reviews all grievance and appeal policies. At least quarterly, the Governing Board reviews the activities of all quality committees. SFHP also conducts a review and analysis on at least a quarterly basis, of all recorded grievances related to access to care, quality of care and denial of services, and takes appropriate action to remedy any system problems identified in such reviews. Annually, the Governing Board reviews the Quality Improvement Evaluation, which includes tabulated grievance data, an evaluation of grievance and complaint trends, member satisfaction survey results and related data. The Quality Improvement Evaluation also proposes priority areas for improvement, and related activities and goals. The Governing Board may direct SFHP to improve the quality and efficiency of the grievance process, or to initiative improvement activities that directly address the individual or systemic issues raised. Reporting of Grievances to the State 14 P age

15 SFHP submits a quarterly grievance report to DHCS and DMHC using their respective report templates. SFHP submits an annual grievance report to DHCS, DMHC, and MRMIB using their respective report templates. DEFINITIONS 1. Grievance: a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and may include a complaint, dispute, request for reconsideration or appeal made by an enrollee or the enrollee s representative to SFHP or to any entity with delegated authority to resolve grievances on behalf of SFHP. Where the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance. 2. Complaint: is the same as grievance. 3. Member Appeal: a request to reconsider an initial denial decision of clinical services or pharmaceuticals that were requested but had not yet occurred. 4. Complainant: is the same as grievant, and means the person who filed the grievance including the enrollee, a representative designated by the enrollee, or other individual with authority to act on behalf of the enrollee. 5. Resolved: the grievance has reached a final conclusion with respect to the member s submitted grievance, and there are no pending member appeals within the plan s grievance system, including entities with delegated authority. 6. Expedited review: an accelerated review and reporting process for grievances involving an imminent and serious threat to the member s health. An imminent and serious threat to health includes, but is not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of the health of the member. 7. Independent medical review (IMR): The expert review of disputed health care services by an outside organization that contracts with the Department of Managed Health Care (DMHC). 8. Disputed health care service: Any health care service that is eligible for coverage and payment by SFHP or medical group that has been delayed, denied or modified by a decision of SFHP or one of its medical groups. The decision to delay, deny or modify must be made, in whole or in part, due to a finding that the service is not medically necessary. 9. Notice of Action (NOA): a formal letter telling members that a medical service has been denied, deferred, or modified. 10. Clinical Grievance: a clinical grievance is defined as any issue concerning the services provided by a clinic, hospital, provider or pharmacy. The types of grievances considered to be clinical in nature include: Quality of Service (by clinic/hospital/provider) Access 15 P age

16 Pharmacy issues Quality of Medical Care Denials, Refusals (formulary, denial of service/treatment) Cultural, Linguistic, and Health Education (by clinic/hospital/provider) 11. Non-Clinical Grievance: a non-clinical grievance is defined as any issue concerning the services provided by SFHP and its non-clinical components. The types of complaints considered to be non-clinical in nature include: Billing Benefits/Coverage (benefits, does not like HMO business rules) Cultural, Linguistic, and Health Education (by SFHP staff, SFHP materials) Quality of Service (by SFHP staff) Enrollment (cancellation of coverage, premium increase) 12. Potential Quality Issue (PQI): these are potential issues with the quality of care or service delivered by a practitioner. SFHP provides a mechanism for peer review for PQIs in the form of a committee that meets to evaluate the need to alter the practitioner s participation in its health care delivery system based on evidence of serious quality deficiencies. The Plan also provides reports to the Medical Board of CA and other reporting agencies as required. PQIs include provider preventable conditions (PPC). As defined by federal regulations, PPCs are healthcare acquired conditions (HCAC) in inpatient hospital settings, as well as other providerpreventable conditions (OPPC) in all healthcare settings. 13. Provider Appeal: request to reconsider an initial denial decision of clinical services or pharmaceuticals that were requested that have not occurred or have occurred where it is not done on the behalf of the member. REFERENCES 1. MMCD All Plan 03009: Expedited State Hearings 2. MMCD All Plan 03008: Submission of Quarterly Logs 3. Title 28, California Code of Regulations, Section Title 22, California Code of Regulations, Section 53858, 53893, Health and Safety Code, Sections ,1368, , , , , , , , , , and Welfare and Institutions Code Code of Federal Regulations, Title 42, Section (b)3 8. MMCD Policy Letter : Timeframes for Member Grievances 16 P age

17 San Francisco Health Plan 1. ACCESS 1.1 Long Wait for an Appointment 1.2 Unavailable: Provider 1.3 Unavailable: Telephone 1.4 Out of Network Services 1.5 Long Wait after appointed time 1.6 Long Wait at Urgent Care Facility or ER Other 1.7 ADA Access 1.9 Other 2. QUALITY OF MEDICAL CARE 2.1 Delay of Care 2.2 Disagreement with Diagnosis 2.3 Disagreement with Treatment 2.4 Inappropriate Care 2.5 Inadequate Facilities 2.6 Lack of Care 2.7 Modification of Care 2.8 Denial of Care 2.9 Other 2.10 Coordination of Care 3. QUALITY OF SERVICE 3.1 Poor Attitude 3.2 Poor Communication 3.3 Slow Reply 3.4 Administrative Services 3.5 Pharmacy/UM Authorization 3.9 Other 4. BENEFITS/COVERAGE 4.1 Dispute over Benefits 4.2 Does not like Benefit 4.3 Does not like HMO business rules 4.5 Exclusions and Limitations 4.6 Formulary 4.9 Other 5. DENIALS/REFUSALS 5.1 Denial of Service or Treatment 5.2 Denial of Experiment/Investigational Procedure 5.3 Denial of Emergency/Urgent Service 5.4 Refusal to Pay for Treatment 5.5 Refusal to Refer 5.6 Pharmacy denial and/or modification 5.7 Refusal to Pay for Equipment 5.9 Other 6. BILLING 6.1 Inappropriate Billing 6.2 Insufficient Payment 6.3 Slow Payment 6.4 Co payment 6.9 Other 7. ENROLLMENT 7.1 Cancellation of Coverage 7.2 Non Acceptance of Coverage 7.3 Premium Refund Request 7.4 Kaiser 7.5 Premium Increase 7.6 Dis enrollment 7.7 Clinic closed 7.9 Other 8. CULTURAL, LINGUISTIC & HEALTH EDUCATION 8.1 Lack of Interpreter 8.2 Lack of Health Education Program 8.3 Lack of Cultural Sensitivity 8.4 Lack of Translated Materials 8.5 Inappropriate Literacy Level 8.9 Other 9. OTHER 10. CBAS 10.1 Appeal inability to receive services or receiving more limited services than requested 10.2 Appeals related to requesting a CBAS Provider and inability to access provider 10.3 Excess travel times to access CBAS 10.4 Grievances regarding CBAS Providers 10.5 Grievances regarding CBAS assessment and/or reassessment For each grievance a third level of categorization will identify the source of the grievance (i.e. the location or entity that has caused the grievance to occur) 1. SFHP 2. Medical Group 3. Hospital 4. Clinic 5. PCP 6. Specialist 7. Ancillary Services 8. Pharmacy 9. Other 10. Transportation 11. CBAS These categories have been developed taking into consideration the reporting requirement for the DMHC, DHCS and MRMIB. 17 P age

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19 If you need assistance to translate this letter in another language, please contact San Francisco Health Plan at (800) 若 您 需 要 將 此 函 翻 譯 成 其 他 語 言, 請 聯 絡 San Francisco Health Plan, 電 話 (800) Si necesita ayuda para traducir esta carta a otro idioma, comuníquese con San Francisco Health Plan al (800) Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc San Francisco Health Plan theo số (800) ACKNOWLEDGEMENT Date «FName» «LName» «Address» «City», «State» «Zip» SFHP ID Number: «SFHP_ID» «LOB» Dear Member / Parent / Guardian: San Francisco Health Plan has received an expression of dissatisfaction from you with one of our areas of service: By: «VIA» On: «GDATE» We call an issue like this a grievance. We will work with you or your representative to find a solution to your grievance in the next 30 days. If you believe your grievance involves an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function, please contact me immediately. Grievance Coordinator San Francisco Health Plan 201 Third Street, 7 th Floor San Francisco, CA (415) or (800) The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you Page 19 of 24

20 should first telephone your health plan at (415) or (800) and use your health plan s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888) HMO-2219 and a TDD line (877) for the hearing and speech impaired. The department s Internet Web site has complaint forms, IMR application forms and instructions online. Attention Medi-Cal members: If you receive Medi-Cal, you or your representative can request a State Fair Hearing. If you believe there is a serious threat to your health you may also file for an expedited State Fair Hearing. Your representative is a friend, relative or lawyer that you ask to represent you. If you decide to request a hearing, you must do so within 90 days of the mailing of this notice. If you ask for a State Fair Hearing within 10 days of the notice to delay, modify or deny health care services, current services will be authorized until a State Fair Hearing decision is made. Information about the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box , MS , Sacramento, CA, , or by calling (800) The TDD number is (800) The forms you need are also available from the San Francisco Department of Human Services by calling (415) The TDD is (415) You have a right to examine the materials that make up the record for the State Fair Hearing decision. Any information you provide may be shared with the Department of Social Services or with the United States Department of Health and Human Services. You can locate your record by contacting the Public Inquiry and Response Unit at (800) The Public Inquiry and Response Unit also can help you find someone to represent you at the hearing, or you can ask someone to represent you, or represent yourself. The State of California Office of the Ombudsman will also help you with your grievance and State Fair Hearing. You can call them, toll-free, at (888) The TDD number is (800) Its office hours are Monday-Friday, 8 a.m. to 5 p.m., closed on State holidays. Please contact me by phone or mail any time you have a question or need assistance. You can reach me through the Customer Services Department at (415) or Page 20 of 24

21 (800) I will do my best to further assist you. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday. Sincerely, Grievance Coordinator San Francisco Health Plan NOTE: Add CC: to member if grievance comes from member representative (i.e. provider) Page 21 of 24

22 If you need assistance to translate this letter in another language, please contact San Francisco Health Plan at (800) 若 您 需 要 將 此 函 翻 譯 成 其 他 語 言, 請 聯 絡 San Francisco Health Plan, 電 話 (800) Si necesita ayuda para traducir esta carta a otro idioma, comuníquese con San Francisco Health Plan al (800) Nếu quý vị cần hỗ trợ dịch thư này sang một ngôn ngữ khác, vui lòng liên lạc San Francisco Health Plan theo số (800) CLINICAL GRIEVANCE RESOLUTION Date «FName» «LName» «Address» «City», «State» «Zip» SFHP ID Number: «SFHP_ID» «LOB» Dear Member / Parent / Guardian: San Francisco Health Plan (SFHP) received your expression of dissatisfaction by «VIA» on «GDATE». An issue like this is a grievance and we understood it as follows: «DESCRIPTION» We have reviewed your grievance carefully and «RESOLUTION[For appeals include pertinent citations from EOC, guideline, criteria, etc.]» We believe this resolves your grievance. If not, you or your representative may contact us by phone or mail if you have any additional questions or need assistance. Our office hours are from 8:30 a.m. to 5:30 p.m. Monday through Friday. Page 22 of 24

23 Nicole A. Ylagan Clinical Quality Coordinator San Francisco Health Plan 201 Third Street, 7 th Floor San Francisco, CA Phone: (415) If you believe your grievance involves an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb or major bodily function, please contact me immediately. Also, read below about your rights to contact the State immediately for a resolution of your urgent grievance. The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (415) or (800) and use your health plan s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been resolved satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR with the Department of Managed Health Care, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number: (888) HMO-2219 and a TDD line: (877) for the hearing and speech impaired. The department s Internet Web site has complaint forms, IMR Application forms and instructions online. Attention Medi-Cal members: If you receive Medi-Cal, you or your representative can request a State Fair Hearing. If you believe there is a serious threat to your health you may also file for an expedited State Fair Hearing. Your representative is a friend, relative or lawyer that you ask to represent you. If you decide to request a hearing, you must do so within 90 days of the mailing of this notice. If you ask for a State Fair Hearing within 10 days of the notice to delay, modify or deny health care services, current services will be authorized until a State Fair Hearing decision is made. Information about the State Fair Hearing process is available by writing the California Department of Social Services (CDSS), State Hearing Division, PO Box , MS , Sacramento, CA, , or by calling (800) The TDD number is (800) The forms you need are Page 23 of 24