CALIFORNIA - Pacificare Health Systems

PART A
Quality of Care Review
114
Overseeing Your Health Care
All quality of care complaints requiring clinical
review are reviewed by PacifiCare’s Health Services
department. Complaints affecting your immediate
condition are reviewed immediately. PacifiCare
conducts this review by investigating the complaint
and consulting with your Participating Medical Group,
treating Providers and other PacifiCare departments.
We also review medical records as necessary, and you
may need to sign an authorization to release your
medical records.
We will notify you in writing regarding your quality
of care review within 30 days of receipt of your
complaint. The results of the quality of care review
are confidential and protected from legal discovery
in accordance with California law. Please refer to
“Expedited Review Appeals” for Appeals involving an
imminent and serious threat to your health, including,
but not limited to, severe pain or the potential loss of
life, limb or major bodily function.
If a Member has asserted a claim for benefits or
reimbursement as part of a quality of care complaint,
the claims for benefits or reimbursement will be
reviewed through the Appeals Process described below.
The Appeals Process
PacifiCare’s Health Services department will review
your appeal within a reasonable period of time
appropriate to the medical circumstances and make
a determination not later than 30 calendar days of
PacifiCare’s receipt of the appeal. For appeals involving
the delay, denial or modification of health care services
related to Medical Necessity, PacifiCare’s written
response will include the specific reason for the
decision, describe the criteria or guidelines or benefit
provision on which the denial decision was based,
and notification that upon request the Member may
obtain a copy of the actual benefit provision, guideline
protocol or other similar criterion on which the denial
is based. For determinations delaying, denying or
modifying health care services based on a finding that
the services are not Covered Services, the response
will specify the provisions in the Combined Evidence
of Coverage and Disclosure Form that exclude that
coverage. If the complaint is related to quality of care,
the complaint will be reviewed through the procedure
described in the section of this Combined Evidence
of Coverage and Disclosure Form captioned, “Quality
Management Review.”
Expedited Review Process
Appeals involving an imminent and serious threat
to your health, including, but not limited to, severe
pain or the potential loss of life, limb or major bodily
function, will be immediately referred to PacifiCare’s
clinical review personnel. If your case does not meet
the criteria for an expedited review, it will be reviewed
under the standard appeal process. If your appeal
requires expedited review, PacifiCare will immediately
inform you in writing of your review status and your
right to notify the Department of Managed Health Care
of the grievance and provide you and the Department
of Managed Health Care with a written statement of
the disposition or pending status of the expedited
review no later than three (3) days from receipt of the
grievance. The DMHC may waive the requirement that
you complete the appeals process or participate in
the appeals process for at least 30 days if the DMHC
determines that an earlier review is necessary.
Voluntary Mediation and Binding Arbitration
If you are dissatisfied with PacifiCare’s Appeal Process
determination, you have 60 days to request that
PacifiCare submit the appeal to voluntary mediation
or binding arbitration before the Judicial Arbitration
and Mediation Services (JAMS). However, if you have
a legitimate health or other reason that prevents you
from electing binding arbitration within 60 days,
you will have as long as is reasonably necessary to
accommodate your special needs to elect binding
arbitration. Binding arbitration is determined through
a single arbitrator. The Member may file a grievance
with the Department of Managed Health Care, upon
the earlier of completing mediation or participating in
PacifiCare’s grievance process or voluntary mediation
for 30 days. Such voluntary mediation or binding
arbitration will be limited to claims that are not subject
to the Employee Retirement Income Security Act of
1974 (ERISA).
Voluntary Mediation
In order to initiate voluntary mediation, either you or
the agent acting on your behalf must submit a written
request to PacifiCare. If all parties mutually agree to
mediation, the mediation will be administered by
JAMS in accordance with the JAMS Mediation Rules