Rights and responsibilities
Our providers and members have rights and responsibilities. Our member services representatives serve as advocates for our members. Below are the rights and responsibilities of members and the process for providers filing grievances and appeals, either on behalf of the member or themselves.
Members have the right to:
- Be treated with respect and with due consideration for their dignity and privacy
- Expect that we will treat their records, including medical and personal information and communications, confidentially
- Request and receive a copy of their medical records at no cost to the member, and request that the records be amended or corrected
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation as specified in federal regulations
Take part in decisions regarding their health care
- Receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand
- Engage in candid discussions of appropriate or medically necessary treatment options for their conditions regardless of cost or benefit coverage
- Receive the appropriate services that are not denied or reduced solely because of medical condition
- Refuse health care (to the extent of the law) and understand the consequences
- Decide ahead of time the care they want if they become sick, injured or seriously ill by making a living will
- Be able to make decisions about their children’s health care if members are younger than age 18 and married, pregnant or have children
Grievances, appeals and fair hearings
- Pursue resolution of grievances and appeals about the health plan or care provided
- Freely exercise filing a grievance or an appeal without adversely affecting the way they are treated
- Continue to receive benefits pending the outcome of an appeal or a fair hearing under certain circumstances
Anthem Blue Cross (Anthem) information
- Receive the necessary information to be an Anthem Blue Cross (Anthem) member in a manner and format they can understand easily
- Receive a current member handbook and a provider directory
- Receive a copy of the member handbook and/or provider directory by request by calling the Customer Care Center:
- If you live outside L.A. County, call 1-800-407-4627
- If you live in L.A. County, call 1-888-285-7801
- Receive assistance from Anthem in understanding the requirements and benefits of the plan
- Receive notice of any significant changes in the benefit package at least 30 days before the intended effective date of the change
- Make recommendations about our rights and responsibilities policies
- Know how we pay our providers
- Choose their PCPs from our network of providers
- Choose any Anthem network specialist after getting a referral from their PCPs, if appropriate
- Be referred to health care providers for ongoing treatment of chronic disabilities
- Have access to their PCPs or backups 24 hours a day, 365 days a year for urgent or emergency care
- Get care right away from any hospital when their symptoms meet the definition of an emergency medical condition
- Get post stabilization services following an emergency medical condition in certain circumstances
- Be free from discrimination and receive covered services without regard to race, color, creed, gender, religion, age, national origin ancestry, marital status, sexual preference, health status, income status, program membership, or physical or behavioral disability, except where medically indicated
Members have the responsibility to:
Respect their health care providers
- Treat their doctors, their doctors’ staff and Anthem employees with respect and dignity
- Not be disruptive in the doctor’s office
- Make and keep appointments and be on time
- Call if they need to cancel an appointment or change the appointment time or call if they will be late
- Respect the rights and property of all providers
Cooperate with the people providing health care
- Tell their providers about their symptoms and problems and ask questions
- Supply information providers need in order to provide care
- Understand the specific health problems and participate in developing mutually agreed-upon treatment goals as much as they are able
- Discuss problems they may have with following their providers’ directions
- Follow plans and instructions for the care they have agreed to with their practitioners
- Consider the outcome of refusing treatment recommended by a provider
- Discuss grievances, concerns and opinions in an appropriate and courteous way
- Help their providers obtain medical records from their previous providers and help their providers complete new medical records as necessary
- Secure referrals from their PCPs when specifically required before going to another health care provider unless they have a medical emergency
- Know the correct way to take medications
- Go to the emergency room when they have an emergency
- Notify their PCPs as soon as possible after they receive emergency services
- Tell their doctor who they want to receive their health information
Follow Anthem policies outlined in the member handbook
- Provide us with proper identification during enrollment
- Carry their Anthem and Medicaid ID cards at all times and report any lost or stolen cards
- Contact us if information on their ID cards is wrong or if there are changes to their name, address or marital status
- Call us and change their PCP before seeing the new PCP
- Tell us about any doctors they are currently seeing
- Notify us if a member or family member who is enrolled in Anthem has died
- Report suspected fraud and abuse
Providers filing grievances and appeals
Provider grievances and appeals are classified into the following two categories:
- Grievances relating to the operation of the plan including benefit interpretation, claim processing, and reimbursement.
- 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  calendar days from the date the provider became aware of the issue
- By fax, or
- verbally by calling the Customer Care Center
- 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.
- 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.
- 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
- The grievance is then assigned to the appropriate G&A associate to investigate the provider’s grievance to propose a resolution.
- 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.
- Anthem’s designated staff will send a written resolution letter to the provider within  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:
- 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.
- 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)
- Medi-Cal Program:
- 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.
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