California Code of Regulations › Title 22 - Social Security › Division 7 - Health Planning and Facility Construction › Chapter 9.2 - Hospital Fair Billing Program › Article 4 - Hospital Bill Complaint Program › Section 96051.16 - Filing a Patient Complaint

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Complaints to the Department pursuant to Health and Safety Code section
				  127436
				  may be made electronically or in writing and must be signed by the patient or
				  their authorized representative. The Department will make the information
				  required by subsection (b) available through its online patient complaint
				  portal or by mail upon the patient's request.
(b) A complaint submitted by a patient, or
				  their authorized representative, shall include the following information:
(1) Full name of patient.
(2) Name of parent, guardian, or conservator,
				  if filing for a minor child.
(3)
				  Date of birth.
(4) Sex.
(5) Family size pursuant to Health and Safety
				  Code section
				  127400
				  (h).
(6) Mailing address, if available.
(7) Primary phone number, if
				  available.
(8) Secondary phone
				  number, if available.
(9) Email
				  address, if available.
(10)
				  Preferred language (optional).
(11)
				  Hospital name and address.
(12)
				  Date of service(s) being billed by hospital.
(13) Health plan, insurance plan, and/or
				  government insurance program that patient was enrolled in at the time hospital
				  services were provided, if applicable, and membership numbers, if
				  available.
(14) Health plan(s) or
				  insurance provider(s) that processed and paid claims for hospital service(s) in
				  question, including supporting documentation, if applicable and
				  available.
(15) Date patient filed
				  grievance(s) with health plan about any denial(s), including health plan's
				  response and date grievance was resolved, if applicable and
				  available.
(16) Date of injury if
				  hospital services resulted from injury caused by a third party, including, but
				  not limited to, car accident, work injury, or crime.
(17) Date patient submitted a discount
				  payment program and/or charity care program application to hospital, and
				  whether it was approved or denied, if applicable and available.
(18) Date patient appealed hospital's denial
				  of discount payment and/or charity care application, if applicable and
				  available.
(19) Copy of hospital
				  notice(s) and billing statement(s) received, if applicable and
				  available.
(20) Copy of proof of
				  payment for any amount(s) paid to hospital for services in question, including
				  date of last payment, if applicable and available.
(21) Date hospital sold debt to collections
				  or date patient was notified bill in jeopardy of being sent to debt
				  collections, if applicable and available.
(22) Documentation that hospital debt was
				  reported to a credit bureau and credit report/score was impacted, if applicable
				  and available.
(23) A signed
				  authorization for release of information pursuant to section
				  96051.15.
(24) A signed authorized representative
				  designation pursuant to section
				  96051.14, if applicable.
(25) A signed acknowledgement that the
				  Department provided the patient and/or authorized representative with a notice
				  of rights pursuant to the Information Practices Act of 1977.
(26) Signature of patient or authorized
				  representative with legal authority to represent the patient.