Member Grievances
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Governs CenCal Health’s receipt, documentation, investigation, review, resolution, and notification processes for Member Grievances involving Member Services, Grievance and Appeals, Medical Management, Quality, Compliance, Members, representatives, and providers.
The policy was moved to a new P&P template as part of the 2024 integration process.
The restructuring of MS-20 created a more specific policy focused on member grievances with minimal changes.
Grievance Routing and Review Pathways
Grievance routing and review pathways
Apply the pathway that matches the grievance subject, filer, urgency, and clinical component. Special subject-based routes take precedence over the standard process.
Authorized filer
- The grievance is submitted by the Member or the Member's appointed representative, with the required verbal authorization or Appointment of Representative Form.
- The grievance is submitted by a provider on behalf of the Member, and the Member participates and provides verbal or written consent authorizing the provider to act.
Subject-based routing
- The grievance concerns Medi-Cal pharmacy benefits.
Do not initiate the grievance through CenCal Health. Transfer the Member or appointed representative to Medi-Cal Rx through Magellan Rx at 1-800-541-5555 or TTY 1-800-430-7077; provide assistance requested by Magellan Rx.
- The grievance alleges discrimination.
Immediately forward it to the Compliance Investigator for investigation separate from the standard grievance process and required reporting to the Office for Civil Rights.
- The grievance concerns specialty mental health services.
Forward clinical and non-clinical grievances to Santa Barbara County Behavioral Wellness Department or MHS of San Luis Obispo, as applicable. CenCal Health staff initiate and investigate mild-to-moderate behavioral health grievances.
Urgency pathway
- The grievance meets DHCS criteria for expedited handling.Outcome within 72 hours (3 calendar days)
Review immediately through Medical Management or a licensed clinical professional and provide the outcome to the requestor within the allowable review period.
- The grievance does not meet DHCS expedited criteria.Standard resolution within 30 calendar days
Process it under the standard grievance process. Notify the requestor verbally and in writing that the request was downgraded and advise of the right to grieve the downgrade.
Clinical review pathway
- The grievance has a clinical component.
Route it through Medical Management for review by an appropriately independent physician reviewer. The reviewer must not have reviewed the initial request, participated in a prior decision, or be subordinate to someone involved in the initial review or decision.
- The grievance is non-clinical.
Route it to the Quality Improvement Manager for non-clinical review and quality-improvement follow-up.
Categorization, Screening, and Required Timeframes
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Member Grievance Handling Requirements
Maintain grievance access
Maintain a Member Grievance system that allows Members or appointed representatives to submit grievances by phone, in person, or in writing. The system covers concerns about CenCal Health, network providers, care received, benefits, and other dissatisfaction not related to an Adverse Benefit Determination.
Record and route grievances
Document all Standard and Expedited Grievances in CenCal Health’s online tracking system as soon as they are identified. Immediately alert appropriate staff and forward discrimination grievances to the Discrimination Grievance Coordinator for investigation outside the standard grievance process.
Provide accessibility assistance
Provide assistance with grievance forms and coordinate auxiliary aids, translation of materials, alternative formats, interpreter services, and TTY/TDD access. CenCal Health’s toll-free TTY/TDD number is 1-833-556-2560.
Forward clinical documentation
Forward initial grievance documentation to the Plan’s Medical Management Team or a licensed clinical professional within two business days of receipt. Expedited grievances must be forwarded immediately, with medical records, chart notes, and related documentation coordinated when clinical review is needed.
Retain plan responsibility
CenCal Health must retain responsibility for the Member Grievance system. This responsibility may not be delegated to the provider network.
Validate grievance filer authority
Accept grievances from Members or appointed representatives. A provider may file on a Member’s behalf only when the Member provides verbal or written consent, and an appointed representative must provide at least verbal authorization or submit an Appointment of Representative Form when required.
Route pharmacy grievances to Medi-Cal Rx
Do not initiate a CenCal Health grievance for Medi-Cal pharmacy benefits. Transfer the Member or appointed representative to the Medi-Cal Rx Customer Service Center through Magellan Rx at 1-800-541-5555 or TTY 1-800-430-7077, and provide any assistance requested by Magellan Rx.
Intake and register grievances
Accept grievances by telephone, grievance form, in person, or correspondence. Document the Member’s information and confirmation to file, enter the grievance into the online tracking system, and allow filing at any time without a filing deadline.
Protect confidentiality
Protect Member confidentiality when someone other than the Member, provider, or appointed representative contacts CenCal Health. Document the information received, do not disclose confidential Member information, and refer the matter for Member validation.
Conduct prompt follow-up
Have the G&A Coordinator contact the Member or appointed representative within one business day of receiving the grievance. Mail requested grievance forms no later than the next business day after the request.
Code and clinically screen grievances
Assign a category code to each grievance and validate dates of service and other information with the appropriate provider offices. Assess whether a clinical component exists and obtain Health Services Nurse verification of the coding and need for clinical review.
Perform non-clinical and clinical review
Route non-clinical grievances to the Quality Improvement Manager for review, documentation, and quality-improvement follow-up. Route clinical grievances through Medical Management to an appropriately independent physician reviewer.
Ensure independent physician review
Use a physician reviewer who did not review the initial request or participate in any prior decision. The reviewer also may not be subordinate to anyone involved in the initial review or decision.
Escalate serious quality concerns
Refer sentinel events, serious injury or death, or significant variation from accepted standards of care to the CenCal Health Peer Review Committee for review and determination of any further follow-up.
Process expedited grievances
Review expedited requests immediately and determine whether DHCS expedited criteria are met. Resolve qualifying expedited grievances within 72 hours, with verbal and written outcome notification; downgrade non-qualifying requests to the standard 30-day process and notify the requestor of the downgrade and right to grieve it.
Process exempt grievances
Resolve Exempt Grievances by the next business day and review them daily for coding and process accuracy. Convert an exempt inquiry to a standard grievance when warranted and follow the standard grievance process.
Process discrimination grievances
Immediately forward discrimination grievances to the Compliance Investigator. Investigate them separately from the standard grievance process, do not enter them into the online grievance tracking system, and complete required Office for Civil Rights reporting.
Route behavioral health grievances
Forward specialty mental health grievances to the applicable county behavioral health entity: Santa Barbara County Behavioral Wellness Department or Mental Health Services of San Luis Obispo. CenCal Health staff initiate and investigate mild-to-moderate behavioral health grievances and enter them into the online tracking system.
Notify Members of grievance disposition
Send written acknowledgment of the Member’s grievance within five calendar days and provide a clear written explanation of the decision within 30 calendar days. Notifications must use required language and comply with nondiscrimination, language assistance, accessibility, translation, font, format, and contract requirements.
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