Section 6: Dispute
Resolution and the
6.1 Overview
6.2 Provider Dispute Resolution
6.4 Member Complaints and the Alliance Grievance Process
6.5 Member Rights in the Alliance Grievance Process
Plan members and network providers may access the Dispute Resolution and Grievance process at any time. The processes for both members and providers are presented in this section. All necessary forms can be found in Section 7 - Forms, in this Provider Manual.
To ensure that
Providers may file disputes regarding medical,
administrative, contractual and payment issues.
Such disputes must be filed with the
1. Dispute
Resolution Process
a. Disputes
must be submitted in writing either by
hardcopy or by email. Mail or deliver
your hardcopy dispute to:
ATTN: Grievance Coordinator
Scotts
Email your electronic dispute to GrievanceCoordinator@ccah-alliance.org.
b. Disputes
must include the following information:
§
Provider
name
§
Provider
§
Provider
contact information
§
A clear
explanation of the matter at issue
§
Your
position on the matter.
§
If the
dispute involves a claim or request for reimbursement of overpayment, you also
must include
·
Original
claim number – The original claim number will become the dispute number for
tracking purposes.
·
Clear
identification of the disputed item
·
Date of
service
·
Clear
explanation of why you believe the payment or other action is incorrect.
§
If the
dispute involves members you must include
The
provider may also include any supporting clinical information if
applicable. The
c. Substantially
Similar Multiple Disputes Regarding Claims, Billing or Contractual Issues (Multiple
Dispute).
If a provider has multiple disputes addressing one issue the Provider may file a single dispute using the system described below. This type of dispute will be called a multiple dispute. Please include a list of each individual dispute, identified as stated below, with the other required information for filing the multiple dispute.
1. Claims
or Billing “Multiple Disputes”
The “multiple dispute” filed will be numbered with the
Provider’s
Example – Provider with provider ID number 9999 submits
a “multiple dispute” regarding disputes on the same or substantially similar
issue on January 1, 2004. There are five
claims numbered 00000323864 – 00000323868, each of which will be identified in
the dispute. The “multiple dispute” will
be numbered 9999/010104. Each claim
within the “multiple dispute” would be identified by its’ original claim number
on the list submitted with the dispute.
2. Contractual
or Administrative Multiple Disputes
The “multiple dispute” will be numbered with the provider’s
Example – Provider with ID number 9999 submits a
“multiple dispute” regarding a number of administrative issues (3). The dispute will be numbered 9999/010104 and
each individual dispute within the batch will be (a), (b) and (c).
d. The
e. The
The Provider Dispute form can be found in Section 7 - Forms, in this Provider Manual.
For assistance in filing a Provider Dispute, please contact Plan’s Grievance Coordinator at (831) 430-5525.
Plan members have the right to file complaints about their experiences with the plan or providers. We recognize that most providers have their own internal mechanisms for handling and resolving patient complaints. In addition to your own systems or procedures for this, as a network provider you must also have the following materials available for Medi-Cal, Healthy Families, Healthy Kids, and Alliance Care IHSS Program members:
1. “Frequently Asked Questions About the
2. Plan Grievance Forms (in English and Spanish)
Copies of the above listed documents can be found in Section 7 - Forms, in this provider manual, for your reference and convenience.
(a) When a member complaint is brought to Contractor’s attention, Contractor shall investigate such complaint and use its best efforts to resolve such complaint in a fair and equitable manner. Contractor shall cooperate with Plan in identifying, processing and resolving all member complaints pursuant to Plan’s member grievance procedures. Such cooperation will include, but not be limited to, meeting with representatives of Plan upon request, providing information bearing on the complaint to such representatives and taking all reasonable actions suggested by such representatives to resolve the Member’s complaint. Contractor will promptly notify Plan of receipt of all complaints from or on behalf of members. The parties will each promptly notify the other of the receipt of any written complaint letters regarding Services provided to members by or on behalf of Contractor. Contractor shall comply with Plan’s resolution of any such complaints.
(b) Plan is responsible for administration of Covered Benefits. All inquiries regarding what services and benefits are Covered Benefits are to be referred to Plan.
(c) Contractor will promptly notify Plan of any professional liability claims filed or asserted regarding Services provided to members by, or on behalf of, Contractor.
The following pages describe the steps to file a member complaint. Complaint form and information about how to file a complaint can be found in Section 7 - Forms, of this provider manual. These should be available to members in all contracted providers’ offices. If a member asks to file a complaint, the provider’s office should supply these forms and instructions to the member. Providers may refer members with complaints to the Alliance Member Services Department for assistance, or to the plan’s website http://www.ccah-alliance.org. Member complaint forms and instructions are available there, and members may file a complaint electronically.
Members have the right to express their dissatisfaction with any aspect of Plan or its providers. A complaint may be filed by a member or a member’s authorized representative in one of the following ways:
1. In person, by making an appointment to meet with a Member Services Representative (MSR) at one of our three (3) offices:
|
Office |
Address |
|
|
|
|
|
Scotts |
|
|
119 |
|
|
|
|
|
|
|
|
|
2. By calling a Member Services Representative at:
|
Office |
Address |
|
|
(831) 430-5505 |
|
|
(831) 430-5500, ext. 7038 or (800) 700-3874, ext. 7038 |
|
|
(831) 755-8220, ex. 5505 |
The TDD line for the hearing and/or speech impaired is (877) 548-0857
3. By calling the Grievance Coordinator at (831) 430-5525 or toll free (800) 700-3874, ext. 5525.
4. By filling out a Complaint form or putting the complaint in writing and sending it to the Grievance Coordinator at:
ATTN: Grievance Coordinator
Scotts
5.
Electronically, by visiting the
The Grievance Coordinator will send an acknowledgement letter to the member within five (5) calendar days following receipt of the complaint. The letter will state the issue(s) of concern to the Member as understood by Plan, identify the Grievance Coordinator as the person to contact regarding the complaint, notify the member of his/her rights in the grievance process, and inform the member that s/he will receive a proposed resolution letter within thirty (30) calendar days from the date the complaint was received.
Complaints received over the telephone that are not coverage disputes, disputed health care services involving medical necessity or experimental or investigational treatment, and are resolved by the next business day will not require written acknowledgement and response.
A member with Medi-Cal coverage does not have to use
the
Human Resources Agency Monterey County Department of Social Services
P. O. Box 1320 Salinas,
CA 93901
Phone: (831) 454-4117 (831) 755-4477
A member with Healthy Families, Healthy
Kids or Alliance Care IHSS coverage
has to go through the
Informational
notices explaining how enrollees may contact their plan, file a complaint with
their plan, obtain assistance from the Department and seek an independent
medical review are available in non-English languages through the Department’s
web site above. Informational notices in
both English and Spanish may also be found in Section 7.
If members have
questions about their Medi-Cal eligibility or Medi-Cal benefits, they should
not file a complaint with the
Healthy Families members with questions about their
eligibility should be directed to the Healthy Families Program at
1-866-848-9166.
Healthy Kids and
Alliance Care IHSS members may file
complaints about their eligibility and/or disenrollment with the
If the member has
any questions about the steps in the member grievance process, please have the
member call the Grievance Coordinator at (831) 430-5525 or toll free at
800-700-3874, ext. 5525. The member may
also call to make an appointment to come into an
A member of Central Coast Alliance for Health has the following rights in the grievance process:
1. A member can authorize a friend or a family member to act on his/her behalf in the grievance process.
2. If the member does not speak English fluently, s/he has the right to interpreter services.
3. The member has the right to obtain representation by an advocate or legal counsel to assist them in resolving the grievance.
4. The
State Office of the Ombudsman will help Medi-Cal members who are having problems
with the
5. Medi-Cal
members have the right to file a request for a State Fair Hearing with the
California Department of Social Services without going through the
6. Healthy
Families, Healthy Kids, and Alliance Care IHSS members have the right to
request a review by the
7. Healthy Families, Healthy Kids, and Alliance Care IHSS members have the right to request an Independent Medical Review (IMR) if their complaints involves a denial or, or partial denial of, a health care service if it was determined that the service is not medically necessary.
|