Section 51015 - Provider Grievances and ComplaintsWhen a provider of services has a grievance or complaint concerning the processing or payment of his claims for services provided under the Medical Assistance Program the following procedures must be met:
(a) The provider shall initiate an appeal, by submitting a grievance or complaint in writing, within 90 days of the action precipitating the grievance or complaint, to the appropriate fiscal intermediary identifying the claims involved and specifically describing the disputed action or inaction regarding such claims.(b) The fiscal intermediary shall acknowledge the written grievance or complaint within 15 days of its receipt.(c) The fiscal intermediary shall determine whether or not the grievance or complaint shall be referred to professional peer review.(1) When the grievance or complaint is not referred to professional peer review, the fiscal intermediary shall review the merits of the grievance or complaint and send a written decision of its conclusion and reasons therefor to the provider within 30 days of the acknowledgment of the receipt of the grievance or complaint.(2) When the grievance or complaint is referred to professional peer review:(A) All parties concerned shall be notified that the referral has been made to professional peer review and that a final determination will require up to 60 days from the acknowledgment of receipt of the grievance or complaint.(B) The professional peer review shall make its evaluation and submit its findings and recommendations to the fiscal intermediary and the provider within 30 days of the referral from the fiscal intermediary.(C) The fiscal intermediary, after taking into consideration the findings and recommendations of the professional peer review, shall send a written decision to the provider.(d) After these procedures have been followed, a provider who is not satisfied with the appeal decision by the fiscal intermediary, may seek appropriate judicial remedies in compliance with Section 14104.5 of the Welfare and Institutions Code, no later than one year after receiving notice of the decision.Cal. Code Regs. Tit. 22, § 51015
1. Amendment filed 1-25-79; effective thirtieth day thereafter (Register 79, No. 4). For prior history, see Registers 66, No. 30; 68, No. 43; 70, No. 30; and 74, No. 3.
2. Amendment filed 12-6-85; effective thirtieth day thereafter (Register 85, No. 49).
3. Amendment filed 4-2-92; operative 4-2-92 pursuant to Government Code section 11346.2(d) (Register 92, No. 14).
4. Change without regulatory effect amending NOTE filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51). Note: Authority cited: Section 20, Health and Safety Code; and Sections 14104.5 and 14124.5, Welfare and Institutions Code. Reference: Sections 14021, 14053, 14104.5, 14124.24 and 14131, Welfare and Institutions Code.
1. Amendment filed 1-25-79; effective thirtieth day thereafter (Register 79, No. 4). For prior history, see Registers 66, No. 30; 68, No. 43; 70, No. 30; and 74, No. 3.
2. Amendment filed 12-6-85; effective thirtieth day thereafter (Register 85, No. 49).
3. Amendment filed 4-2-92; operative 4-2-92 pursuant to Government Code section 11346.2(d) (Register 92, No. 14).
4. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).