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
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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:
The date and time of receipt of the grievance or appeal;
The name of the member filing the grievance or appeal;
The representative recording the grievance or appeal;
A description of the complaint or problem;
A description of the action taken by the MCP or provider to investigate and resolve the grievance or appeal;
The proposed resolution by the MCP or its medical professional responsible for making utilization management decisions;
The name of the MCP provider or staff responsible for resolving the grievance or appeal; and
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 reviewe...
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