Health Administration Responsibility Project, Inc.
Requirements placed upon
the Department of Managed Care
on/after 1/1/2001
by the Sections of Health and Safety Code affected by
California
AB55 and
SB189
(2) inital and annual notice of grievance procedures
(3) preapprove plans' grievance forms.
(4) require written responses with a clear explanations: eg:
"medical necessity" denials must describe criteria and clinical reasons
"not a covered benefit" denials must specify contract provisions
(5) Require that plans keep grievance files for five years.
(b) Procedures for DMC to review unsatisfied grievances
(1)
(A) Normally 30 days after submission of the grievance.
Procedure to waive the 30 day period for imminent health threat.
(B) prior arbitration unnecessary.
(C) Procedure to refer out appropriate grievance to another governmental entity.
(2) Procedure to allow incompetent enrollees to be represented by agents.
(3) Procedure to determine if grievance is eligible for the Independent Medical Review.
(4) Procedure for administrative penalties for improper medically necessity decisions.
(5) Procedure for written notice of the final disposition within 30 days.
(6) Procedures for ordering plan compliance with DMC decisions.
(8) Procedures for maintaining file of grievances unresolved for >= 30 days.
(9) Procedure for voluntary mediation.
(c) Require each plan to quarterly report grievances unresolved for >=30 days.
(a) Establish the Independent Medical Review System.(IMRS)
(b)(c) Define and distinguish "disputed health care service"
from "coverage decision"
(d)
(1) Define criteria for "disputed health care service" eligibility for IMRS.
Ineligible grievances to be handled per s.1368(b).
(3) Procedure to complete an initial screening of an enrollee grievance.
(e) Assure that every plan contract issued after 1/1/2000, shall,
effective 1/1/2001, provide opportunity for IMR.
Procedure for evaluating such contracts.
(f) Applies to Medi-Cal beneficiaries as well.
(g) Procedures to integrate IMRS with related procedures of
Medicare and Medi-Cal.
(h) Procedures to integrate IMRS with any other procedures or remedies available.
(i) Ensure that by 1/1/2001, every plan publicizes IMRS to its members.
(j)(k)(l) Procedures for enrollee to apply to DMC for IMR.
(m) Procedures for approval of plan IMR application forms.
(n) Procedure to assure that plans produce all required documents within 3 days
of notice of IMR.
(a) Procedure to assure plan's delivery of required documents within 24 hours of
notice of IMR, if there is an imminent health threat, and waiver of plan's grievance
procedure.
(b) Procedure to expeditiously review requests and immediately notify the enrollee
in writing as to whether the request for an independent medical review has been approved.
To the extent a request is not approved, it shall be treated as an immediate request for
departmental review under Section 1368(b).
(c) Procedures to assign an IMR to an independent medical review organization.
(a) Set criteria for qualifying independent medical review organizations (IMROs).
Contract with one or more IMROs in the state.
(c) Criteria to rule out the faintest conflict-of-interest of IMRO personnel.
(d) Procedures to evaluate prospective IMROs.
Develop disclosure forms re conflicts-of-interest.
Evaluation forms for proposed review procedures, personnel policies, etc.
Evaluation forms for Quality Assurance methods.
Evaluation forms for professional competence.
(e) Procedures to make the above information public.