Member Grievances and Appeals of Grievance Resolutions
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Governs CenCal Health's system for receiving, documenting, investigating, resolving, and tracking member grievances and appeals of grievance resolutions, including standard, expedited, exempt, discrimination, mental and behavioral health, and pharmacy-related matters.
CenCal Health implemented an automation enhancement that generates a grievance in the online tracking system when a Member Dissatisfaction code is entered in the HIS Call Tracking System.
The policy was reviewed and approved in April 2024 as part of the NCQA and annual review process.
In October 2023, the policy was checked out for 2024 integration and moved to a new policy and procedure structure.
In July 2023, MS-20 was restructured into more specific policies, including this policy focused on member grievances.
Grievance and Appeal Eligibility, Review, and Timelines
Eligibility and initiation
A grievance or appeal may be initiated by an eligible member, authorized representative, or provider acting with the member’s verbal or written consent, and may be submitted through multiple channels.
Initiation requirements
- The matter concerns CenCal Health, a network provider, care received, a service or benefit, or another expression of dissatisfaction that is not related to an adverse benefit determination.
- The filing is made by the member, an appointed representative with authorization, or a provider acting on the member’s behalf with the member’s participation and verbal or written consent.
Clinical and non-clinical review
Every grievance and appeal is classified as clinical or non-clinical and reviewed using the corresponding process.
Applicable review pathway
- The matter is determined to be non-clinical; the G&A Coordinator assigns the best-fit non-clinical grievance code, and the Member Services Grievance & Appeals QI Manager reviews the documentation, research, findings, and quality-of-service follow-up.
- The matter is determined to be clinical; a California-licensed Clinical Quality Nurse verifies the classification and supports collection of medical records and other documentation for physician review. The physician reviewer must not have participated in the initial request or a prior decision and must not be subordinate to someone who did.
- The physician reviewer identifies a quality-of-care concern that constitutes a sentinel event or significant variation from accepted standards of care; the matter is submitted to the Peer Review Committee for review.
Expedited, standard, and exempt timelines
Processing time depends on whether the matter is expedited, standard, or exempt.
Processing timeline
- The request meets DHCS criteria for expedited processing as determined by the Chief Medical Officer, Medical Director, or physician reviewer.Resolved and outcome provided within 72 hours or 3 calendar days
- The request does not meet expedited criteria and is therefore processed under the standard grievance process.Resolved within 30 calendar days
The requestor receives verbal notice followed by written notice of the downgrade from expedited to standard review and may file a grievance or appeal concerning the downgrade.
- The matter qualifies as an exempt grievance because it can be completely resolved by the next business day, including matters where the member does not want to file a grievance or declines to provide enough information for further investigation.Resolved by the next business day
- The matter follows standard processing.Final written disposition provided no later than 30 calendar days from receipt
Specialized routing and member communications
Discrimination, specialty mental health, pharmacy, language assistance, nondiscrimination, and accessibility requirements require specialized routing or notification handling.
Special handling pathway
- The grievance or appeal alleges an action prohibited by or out of compliance with federal or state nondiscrimination laws.
Immediately forward it to the Compliance Investigator for separate investigation; do not enter it into CenCal Health’s online grievance tracking system.
- The matter concerns specialty mental health services.
Forward documentation to Santa Barbara County Behavioral Wellness Department or Mental Health Services of San Luis Obispo, as applicable.
- The matter concerns mild-to-moderate behavioral health services.
CenCal Health grievance and appeals staff initiate, investigate, and enter the matter into the online tracking system.
- The matter concerns Medi-Cal pharmacy benefits.
Route the member or appointed representative to Medi-Cal Rx through Magellan Rx; CenCal Health does not process these pharmacy grievances and appeals.
- A member notification is issued.
The notification must comply with applicable nondiscrimination, language-assistance, translation, font, format, and accessibility requirements, including required mandated language and documents.
Classification Codes and Operational Timeframes
Provider Participation, Documentation, and Routing
Member Authorization Required for Provider Filing
A provider may file a Grievance on a Member’s behalf only with the Member’s participation and verbal or written consent authorizing the provider to act. A Member or appointed representative must provide at least verbal authorization, or complete or submit the Appointment of Representative Form if it is not already on file.
- Confirm and document the Member’s verbal or written consent before initiating a provider-filed Grievance.
- A Member may submit evidence, testimony, arguments, and other supporting information by telephone or in writing during the review.
Documentation and Clinical Review Support
Support CenCal Health’s intake and clinical review by providing complete, accurate documentation and responding to validation requests. Clinical cases are assembled for Clinical Quality Nurse and physician review, with additional records or information obtained when needed.
- CenCal Health logs Standard and Expedited Grievances and Appeals in its online tracking system as soon as identified; initial documentation and the Member’s issues are forwarded to the Plan’s Clinical Quality Nurse reviewers and Grievance & Appeals QI Manager within two business days, or immediately for an expedited request.
- Respond to requests from the Grievance & Appeals Coordinator to validate dates of service and other information supplied by the Member.
- For clinical cases, provide or assist in obtaining appropriate medical records, charts, chart notes, and other pertinent documentation. The Coordinator reviews provider information and other research and confirms with the Clinical Quality Nurse Reviewer what documentation is needed for physician review.
- The Clinical Quality Nurse verifies the grievance classification, determines whether additional information is required, and applies clinical criteria; additional information may include medical records.
- The Grievance & Appeals Coordinator completes the required documentation and assembles the full physician-review packet. The Clinical Quality Nurse team reviews the packet and prepares a summary for the physician reviewer.
- For expedited cases requiring physician review, provide the completed packet and supporting information promptly. The physician reviewer must be independent of the initial review and any prior decision, and may consult a practitioner in the same or similar specialty; follow-up may be directed to address quality-improvement opportunities.
- Clinical research supporting physician findings is peer-review protected under state law. The physician reviewer provides written confirmation of completion to the Grievance & Appeals Coordinator.
Route Medi-Cal Rx Pharmacy Grievances
CenCal Health does not initiate or process Member Grievances related to Medi-Cal pharmacy benefits. Route the Member or appointed representative directly to the Medi-Cal Rx Customer Service Center through Magellan Rx and provide assistance requested by Magellan Rx.
- Transfer pharmacy-benefit Grievances to the Medi-Cal Rx Customer Service Center through Magellan Rx at 1-800-541-5555; TTY 1-800-430-7077.
- Medi-Cal Rx assumed responsibility for Medi-Cal pharmacy grievance and appeal administration on January 1, 2022.
- CenCal Health may provide Magellan Rx with requested assistance in processing the Member’s pharmacy Grievance.
Route Mental and Behavioral Health Grievances
Specialty mental health Grievances and Appeals must be forwarded to the applicable county mental health entity for resolution. Mild-to-moderate behavioral health Grievances and Appeals remain with CenCal Health staff for initiation, investigation, and online tracking.
- Forward specialty mental health clinical and non-clinical Grievances and Appeals, with summarized documentation, to Santa Barbara County Behavioral Wellness Department or Mental Health Services of San Luis Obispo (MHS-SLO), as applicable.
- If the Member provides full details to CenCal Health, document the issue, offer a warm transfer, advise the Member that the Grievance will be forwarded, and send it to the Plan’s Grievance & Appeals staff for appropriate routing.
- The applicable county QA Manager acknowledges receipt by secure email within one business day and researches and resolves the Grievance directly with the Member.
- CenCal Health Grievance and Appeals staff initiate, investigate, and enter mild-to-moderate behavioral health Grievances and Appeals into the online tracking system.
Key Terms
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