Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

§9775. Grievance and Dispute Resolution Procedure.

(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.

NOTE: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.

HISTORY

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).