California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 4 - Certification Standards for Health Care Organizations › Section 9775 - Grievance and Dispute Resolution Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) HCOs must maintain a grievance procedure
					 under which HCO enrollees or participating providers may submit grievances to
					 the HCO. Each HCO must include a system for resolving disputes which shall
					 include HCO enrollee disputes with a provider and a provider's dispute with the
					 HCO. The HCO must provide that either an HCO enrollee or a provider shall be
					 able to initiate a grievance. Each HCO must provide reasonable procedures which
					 insure adequate consideration of enrollee and provider grievances or disputes
					 and which provide prompt rectification when appropriate.
(b) Compliant forms and a copy of the
					 grievance procedure shall be readily available through each provider facility
					 and through the claims administrator, and shall be furnished promptly upon
					 receipt of a verbal or written request.
(c) If a grievance or dispute concerns the
					 medical reasonableness or medical necessity of treatment recommended by a
					 provider, the HCO must provide for an expedited procedure for review of the
					 grievance or dispute by physicians or qualified professional providers not
					 previously involved in the grievance or dispute and who possess the specialty
					 which is appropriate to the medical nature of the disputed treatment. Under no
					 circumstance may the appeal decision be made by a registered nurse. The HCO
					 must issue a written decision as to the grievance or dispute within 30 days
					 unless the HCO enrollee's medical condition requires a more expedited
					 decision.
(d) Each HCO shall inform
					 providers and HCO enrollees, or their representatives, that they may file a
					 written complaint to the administrative director
(e) The HCO shall annually provide to the
					 administrative director a summary of written grievances received concerning the
					 provision of occupational health services, including the number of total
					 grievances received and processed. Records of all written grievances concerning
					 the provision of occupational health services, including the name of the
					 grievant, the nature of the complaint or grievance, and the manner in which the
					 grievance was resolved or referred for further action, shall be kept by the HCO
					 for a period of not less than 3 years and shall be made available by the HCO to
					 the administrative director as he or she deems necessary.
1. New
						section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only
						pursuant to Government Code section
						11351
						(Register 93, No. 53).
Note: Authority cited: Sections
						  133,
						  4600.5,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600 and
						  4600.5, Labor
						  Code.