Section 96051.17 - Complaint Review(a) For the Department to investigate an eligibility determination by a hospital for its discount payment and/or charity care programs, the patient or their authorized representative must have already submitted an application for discount payment and/or charity care to the hospital for the services at issue in the complaint.(b) Upon receipt of a complaint, the Department will forward the complaint to the hospital for response. (1) The hospital shall respond to the complaint within 30 calendar days unless extended pursuant to section 96051.18.(c) The hospital response to the Department shall include the following:(1) A detailed explanation of the hospital's current position on whether the patient qualifies under the hospital's discount payment and/or charity care policies, including the terms of financial assistance offered, if any.(2) Copies of all documents and information relevant to the issues raised in the complaint, including, but not limited to, bills, written notices, and notes from communications between the hospital and the patient and/or the patient's authorized representative.(d) The Department may request additional information or records from the patient and the hospital at any time during the complaint investigation. (1) The requested additional information or records shall be provided to the Department within 30 calendar days of the request unless extended pursuant to section 96051.18.(e) Upon receipt of all available and relevant information, the Department will make a compliance determination based on the criteria outlined in the Act and this chapter.(f) If the hospital is found to be out of compliance, the Department will issue a preliminary out of compliance notice to the hospital detailing the alleged violation(s). (1) The hospital shall have 30 calendar days after issuance of the preliminary out of compliance notice to respond to the Department.(2) If the hospital does not respond or if the hospital's response does not result in a change in the Department's preliminary out of compliance determination, a letter will be sent to the patient and to the hospital, notifying all parties of the Department's final determination that the hospital is out of compliance with the Act and/or associated regulations, and an administrative penalty is being assessed.(g) If the hospital does not file an appeal within 30 calendar days from the date the Department's final determination notice was issued, the hospital shall do all the following, if applicable:(1) Reimburse the patient any amount owed to the patient, plus interest, pursuant to Health and Safety Code section 127440 within 30 calendar days from the date the final determination notice was issued.(2) Provide the Department with proof of patient reimbursement within 30 calendar days from the date the final determination notice was issued.(3) Pay all assessed penalties to the Department within 30 calendar days after the appeal period pursuant to Health and Safety Code section 127436(c) has ended.(h) If the hospital files an appeal of the Department's final determination, the hospital shall do all the following within 30 calendar days from the date of the Director's written final decision pursuant to section 96051.37, if applicable: (1) Reimburse the patient any amount owed to the patient, plus interest, pursuant to Health and Safety Code section 127440.(2) Provide the Department with proof of reimbursement.(3) Pay all assessed penalties to the Department.Cal. Code Regs. Tit. 22, § 96051.17
Note: Authority cited: Sections 127010 and 127436, Health and Safety Code. Reference: Sections 127436 and 127440, Health and Safety Code.
1. New section filed 11-1-2023; operative 1/1/2024 (Register 2023, No. 44).