Cal. Code Regs. tit. 22 § 96051.16

Current through Register 2024 Notice Reg. No. 43, October 25, 2024

Section 96051.16 - Filing a Patient Complaint

(a) Complaints to the Department pursuant to Health and Safety Code section 127436 may be made electronically or in writing and must be signed by the patient or their authorized representative. The Department will make the information required by subsection (b) available through its online patient complaint portal or by mail upon the patient's request.

(b) A complaint submitted by a patient, or their authorized representative, shall include the following information:

(1) Full name of patient.

(2) Name of parent, guardian, or conservator, if filing for a minor child.

(3) Date of birth.

(4) Sex.

(5) Family size pursuant to Health and Safety Code section 127400 (h).

(6) Mailing address, if available.

(7) Primary phone number, if available.

(8) Secondary phone number, if available.

(9) Email address, if available.

(10) Preferred language (optional).

(11) Hospital name and address.

(12) Date of service(s) being billed by hospital.

(13) Health plan, insurance plan, and/or government insurance program that patient was enrolled in at the time hospital services were provided, if applicable, and membership numbers, if available.

(14) Health plan(s) or insurance provider(s) that processed and paid claims for hospital service(s) in question, including supporting documentation, if applicable and available.

(15) Date patient filed grievance(s) with health plan about any denial(s), including health plan's response and date grievance was resolved, if applicable and available.

(16) Date of injury if hospital services resulted from injury caused by a third party, including, but not limited to, car accident, work injury, or crime.

(17) Date patient submitted a discount payment program and/or charity care program application to hospital, and whether it was approved or denied, if applicable and available.

(18) Date patient appealed hospital's denial of discount payment and/or charity care application, if applicable and available.

(19) Copy of hospital notice(s) and billing statement(s) received, if applicable and available.

(20) Copy of proof of payment for any amount(s) paid to hospital for services in question, including date of last payment, if applicable and available.

(21) Date hospital sold debt to collections or date patient was notified bill in jeopardy of being sent to debt collections, if applicable and available.

(22) Documentation that hospital debt was reported to a credit bureau and credit report/score was impacted, if applicable and available.

(23) A signed authorization for release of information pursuant to section 96051.15.

(24) A signed authorized representative designation pursuant to section 96051.14, if applicable.

(25) A signed acknowledgement that the Department provided the patient and/or authorized representative with a notice of rights pursuant to the Information Practices Act of 1977.

(26) Signature of patient or authorized representative with legal authority to represent the patient.

Cal. Code Regs. Tit. 22, § 96051.16

Note: Authority cited: Section 127010, Health and Safety Code. Reference: Section 127436, Health and Safety Code.

1. New section filed 11-1-2023; operative 1/1/2024 (Register 2023, No. 44).