To: Board of Supervisors
From: Dr. Grant Colfax, Health Services Director
Report Title: Contra Costa Health Plan Grievances and Appeals Report and Log
Recommendation: Recommendation of the County Administrator
RECOMMENDATIONS:
ACCEPT the Contra Costa Health Plan (CCHP) Grievances and Appeals Report and Log, as recommended by the CCHP Joint Conference Committee.
FISCAL IMPACT:
There is no fiscal impact for this action.
BACKGROUND:
The Department of Health Care Services (DHCS) issued the revised All Plan Letter (APL) 21‑011 Grievance and Appeal Requirements, Notice and “Your Rights” Templates on August 31, 2022. APL 21‑011 provides mandatory standards for Medi‑Cal managed care plans’ grievance and appeal systems. The APL requires quarterly reporting of key operational metrics and performance analysis, including specific elements under Sections VII (F), (G) and (H).
• Key reference from APL 21‑011 Section VII (F): The Managed Care Plan (MCP) must maintain a written record for each grievance and appeal received by the MCP. The record of each grievance and appeal must be maintained in a log and include the following information:
o The date and time of receipt of the grievance or appeal;
o The name of the member filing the grievance or appeal;
o The representative recording the grievance or appeal;
o A description of the complaint or problem;
o A description of the action taken by the MCP or provider to investigate and resolve the grievance or appeal;
o The proposed resolution by the MCP or its medical professional responsible for making utilization management decisions;
o The name of the MCP provider or staff responsible for resolving the grievance or appeal; and
o The date of notification to the member of resolution.
• Key reference from APL 21‑011 Section VII (G): The written record of grievances and appeals must be submitted at least quarterly to the MCP’s quality assurance committee for systematic aggregation and analysis for quality improvement. Grievances and appeals reviewed must include, but not be limited to, those related to access to care, quality of care, and denial of services. MCPs must take appropriate action to remedy any problems identified.
• Key reference from APL 21‑011 Section VII (H): The written record of grievances and appeals must be reviewed periodically by the governing body of the MCP, the public policy body, and by an officer of the MCP or designee. The review must be thoroughly documented.
Attachment A - CCHP Q2 2026 Grievance Log and Attachment B - CCHP Q2 2026 Appeals Log are included.
SUMMARY OF SECOND QUARTER OF 2026 GRIEVANCES
Comparing the second quarter of 2026 grievances to the second quarter of 2025 grievances, here is an overview:
• Volume increase: 975 grievances were processed in 2026 Q2. This is a 26% rise from 774 grievances processed in 2025 Q2.
• Issue volume: grievance issues grew to 1,743 in 2026 Q2. This is up 28% from 1,361 grievance issues in 2025 Q2.
• Grievances by type:
o Exempt grievances are up by 550%, from 12 to 78 exempt grievances.
o Expedited grievances are up by 60%, from 15 to 24 expedited grievances.
o Routine grievances are up by 40%, from 1,100 to 1,535 routine grievances.
o “Refused to File” are down by 53% from 224 to 106 grievances.
• Grievances by category:
o Access-related grievances are down by 9.9%.
o Quality of care grievances are up by 35%.
o Quality of service grievances are up by 42%, accounting for about 64% of all issues.
• Top grievance codes:
o 23.2% were the provider direct member billing code.
o 10.3% were the provider/office staff services code.
o 7.2% were the communication code.
o 7.1% were the staff attitude/courtesy code.
o 5.1% were the inappropriate provider care code.
• Corrective Actions: Issued Cease and Desist letters to providers improperly billing Medi‑Cal members under 42 CFR § 447.15. These letters included sample claims and legal references.
• Provider Escalations: No provider received more than a Level 3 high-severity grievance in the past six months.
SUMMARY OF SECOND QUARTER 2026 APPEALS
Comparing the second quarter of 2026 appeals to the second quarter of 2025 appeals, here is an overview:
• Volume Increase: Appeals processed rose by 101%, from 100 appeals processed in 2025 Q2 to 201 appeals processed in 2026 Q2.
• Appeals by Type:
o Expedited appeals increased by 13%, from 15 to 17 appeals.
o Routine appeals increased by 116%, from 85 to 184 routine appeals.
• Appeals by Population:
o 90% of appeals were Medi‑Cal population, which increased from 86 to 164 appeals.
o Appeals in Commercial population were stable, from 14 to 15 appeals.
o Appeals in Dual-eligible Special Needs Plan (D-SNP) population decreased 32% from 15 appeals in 2026 Q1 to 22 appeals in 2026 Q2.
• Appeals per 1,000 Members:
o In Medi‑Cal, appeals increased by 112%.
o In Commercial A, appeals decreased by 60%.
o In Commercial B, appeals increased by 40%.
o In IHSS, appeals increased by 100%.
o In D-SNP, 40.1 appeals per 1,000 members, which is a decrease from 54.7 per 1,000 members in 2026 Q1.
• Reasons for Appeal: Denial or limited authorization reasons accounted for 178 appeals, which is an increase of 85%. And there was only one that was a Claim Dispute.
• Referral Services Requested in 2026 Q2:
o 50 appeals requested Community Supports;
o 22 appeals requested Pharmacy;
o 10 appeals requested Lab;
o 10 appeals requested Diagnostics; and
o 10 appeals requested Enhanced Care Management.
• Outcomes:
o In 2025 Q2, 56% appeals were overturned while 44% were upheld.
o In 2026 Q2, 42% appeals were overturned while 58% were upheld.
§ One appeal was withdrawn and two were dismissed.
• Overturn Rationales:
o Medical Necessity
o Additional Clinical Info
o Medical Director Exceptions
o Timely Access
o Continuity of Care/Claims Issues
Process Improvement: Shared overturned cases with Utilization Management unit to refine workflows and prevent avoidable denials.
Alignment with APL 21‑011
• Section VII (F) Timely Resolution: All grievances and appeals were processed within standard regulatory timelines. The escalation of issues such as provider billing is handled through Cease-and-Desist letters and internal review. This fully satisfies federal and state resolution requirements.
• Section VII (G) Trend Analysis and Corrective Action: The substantial increases, increases of 26% to 101% across categories, triggered a comprehensive pattern-trend review. Notably, billing and quality-of-service issues prompted targeted provider interventions and appeals-analysis feedback loops.
• Section VII (H) Provider/Plan-Level Reporting: No provider has met or exceeded the reporting threshold of more than a Level 3 high-severity grievance in the last six months. High-utilization appeal types and trends by member segment have been reported, and monitoring continues.
CONSEQUENCE OF NEGATIVE ACTION:
If this action is not accepted, it could lead to noncompliance under the federal and state regulations.