Rights and responsibilities

Providers filing grievances and appeals

Provider grievances and appeals are classified into the following two categories:

1. Grievances relating to the operation of the plan including benefit interpretation, claim processing, and reimbursement.
2. Provider appeals of claim determinations including medical reviews related to adverse benefit determinations.

Providers have the right to file a dispute with Anthem for denial, deferral, or modification of a claim is position or post-service request. Providers also have the right to appeal on behalf of a member for denial, deferral, or modification of a prior authorization or request for concurrent review. These appeals are treated as member appeals and following the member appeals process.

Note: Anthem Blue Cross does not discriminate against providers or members for filing a grievance or an appeal. Providers are prohibited from penalizing a member in any way for filing a grievance.

Anthem complies with the contractual requirements on Grievance and Appeals as well as with the California regulations:

• 42 CFR section 438.915
• H&S Code sections 1363.5 and 1367.01
• 28 CCR sections 1300.70(b)(2)(H) and (c)

Provider grievance process

The provider grievance process is communicated in the Provider Operations Manual that each contracted physician receives from the Plan. Providers may file grievances:

• In writing to the Grievance and Appeals (G&A) Unit up to [180] calendar days from the date the provider became aware of the issue
• By fax, or
• verbally by calling the Customer Care Center

1. Grievances should include the provider’s name, date of the incident, and a description of the incident. Providers may also access the  online Physician/Provider Grievance e-form to submit a grievance electronically. Providers may also access this document on the Forms page.
2. Grievances are documented in the electronic tracking system upon receipt and electronically routed to a G&A associate. The provider may also file a grievance on behalf of a member verbally by contacting the Customer Care Center. If a provider files an expedited grievance, it will be considered a grievance request on behalf of a member and will follow our member grievance process.

   Note: there is no time limit for a member to file a grievance.

3. The G&A associate will send a written acknowledgment to the provider acknowledging receipt of the grievance and the receipt date within five calendar days of receipt of the grievance. Then the G&A associate documents the following information regarding the grievance in the Medicaid electronic medical management system for Anthem:
   • The date and time of receipt of grievance
   • The name of the staff person receiving the grievance
   • The name of the staff person responsible for investigation and resolution
   • Member’s name
   • Member’s identification number
   • Grievance type code (including cultural and linguistic codes) including a description of the grievance or problem.
   • Name, tax ID and license number of provider
   • Date of acknowledgment signed by the G&A associate
   • Date of grievance review
   • Action taken by the health plan to investigate and resolve the grievance or problem
   • Date of notification of provider of proposed resolution
4. The grievance is then assigned to the appropriate G&A associate to investigate the provider’s grievance to propose a resolution.
5. Anthem Blue Cross Medicaid may request medical records or a provider explanation of the issues raised in the grievance by telephone or with a signed and dated letter via fax or mail. Providers are expected to comply with the request within 10 calendar days of the date of the request for information for a standard request or within 24 hours of the date of the request for information for an expedited request.
   The investigation will include reviews by appropriate department management and Medical Director, who were not involved in the initial determination. All actions taken are documented in the electronic medical management system and will include:
   • Documentation of the substance of grievance and actions taken.
   • Investigation of the substance of the grievance, including any aspects of clinical care involved.
   • Notification to the provider of the disposition of the grievance and the right to appeal to the state.
6. Anthem’s designated staff will send a written resolution letter to the provider within [30] calendar days of the receipt of the grievance. The resolution letter will notify the provider of the opportunity to file a grievance with those entities that Anthem is a subcontractor.
   Note: According to state law, there are certain grievances that the organization may not be able to inform the provider of the final disposition. In these cases where the company has investigated a provider, and in cases related to quality of care, the organization will notify the provider that the grievance was received and investigated and inform the provider the final disposition cannot be provided due to peer confidentiality laws:
7. When the G&A associate sends the resolution letter to the provider, Anthem closes the grievance file electronically in the electronic medical management system. Any hard copy documents are imaged and saved in the electronic medical management system.
8. If providers are dissatisfied with the grievance resolution, they have the right to file a grievance with:
   • Medi-Cal Program:
     • L.A. Care (in Los Angeles only)
     • The California Department of Managed Health Care (DMHC)
     • Arbitration (handled per the Anthem physician agreement)
   • MRMIP Programs:
     • The California Department of Managed Health Care (DMHC)
     • Arbitration (handled per the Anthem Blue Cross Medicaid physician agreement)
9. Anthem Blue Cross Medicaid prepares quarterly reports, which track and trend provider grievances and presents the report to the Quality Oversight Committee (QOC). The QOC reviews the grievances, including those regarding access to care and quality of care, to identify and address trends. Anthem Blue Cross Medicaid will copy and forward provider grievance letters received and corresponding acknowledgment and resolution notices to those entities, which Anthem is a subcontractor with, upon request.
   All grievances are handled in a confidential manner.  Anthem Blue Cross Medicaid does not discriminate against a provider for filing a standard or expedited grievance. Anthem Blue Cross Medicaid will not take punitive action against a provider for filing a standard or expedited grievance.

Investigation responsibilities are delineated as follows:

Clinical grievances (Quality of care)

All clinical grievances are assigned to G&A clinical associates for review and appropriate action. All practitioners are evaluated for a history of trends during the past 36 months prior to the current grievance. This information is captured on a 36-month rolling report from the electronic medical management system for quality-of-care grievances and a 12 month rolling report for quality-of-service grievances. The clinical associate immediately submits all quality-of-care grievances to a medical director, who was not involved in the initial determination for action unless there is evidence there is no quality-of-care issue or the provider has not responded to requests for information:

• If, upon review of a grievance, a clinically urgent situation is identified, the grievance or problem is processed as expeditiously as the medical condition warrants until a satisfactory resolution is reached on behalf of the member.
• If the clinical situation is not urgent, the grievance or problem is resolved within 30 calendar days of receipt of the grievance.
• A G&A clinical associate may assign a severity level to the case if there is evidence there is no quality-of-care issue, or in the event a provider did not respond to a request for information the medical director makes a determination and assigns a severity level to all other cases:
  • If appropriate, the Medical Director may forward the case to the Physician Quality Improvement Committee (PQIC)/Medicaid Peer Review Committee (Medicaid PRC) for follow up actions

Criteria for clinical grievances is determined using Grievance and Appeal Job Aide Number CG-29 – Administrative versus Clinical Decision Tree.

Administrative grievances (Quality of service)

If the grievance is an administrative grievance, the G&A associate will consult the appropriate Anthem department management staff, who were not involved in the initial determination and who have the authority to take corrective action, for resolution. Cultural and Linguistic (C&L) grievances are coordinated for review and trending with the C&L Specialist. The G&A associate will assign a quality-of-service severity level to each case.