Blue Cross of California Final Report€¦ · Final Report of the Routine Survey March 24, 2015. 933-0303 2 . EXECUTIVE SUMMARY . On August 29, 2013, the California Department of

OFFICE OF PLAN MONITORING DIVISION OF PLAN SURVEYS

FINAL REPORT

ROUTINE SURVEY

OF

BLUE CROSS OF CALIFORNIA

dba ANTHEM BLUE CROSS OF CALIFORNIA

A FULL SERVICE HEALTH PLAN

DATE ISSUED TO PLAN: MARCH 24, 2025 DATE ISSUED TO PUBLIC FILE: APRIL 3, 2015

Template Revision Date: 05/03/19

Final Report of a Routine Survey Blue Cross of California

A Full Service Health Plan March 24, 2015

TABLE OF CONTENTS

EXECUTIVE SUMMARY ________________________________________________ 2

SURVEY OVERVIEW __________________________________________________ 7

SECTION I: DISCUSSION OF DEFICIENCIES AND CURRENT STATUS _________ 9

GRIEVANCES AND APPEALS _________________________________________ 9 GRIEVANCES AND APPEALS BEHAVIORAL HEALTH ONLY ________________ 37 UTILIZATION MANAGEMENT _________________________________________ 40 LANGUAGE ASSISTANCE ___________________________________________ 48

SECTION II: SURVEY CONCLUSION ____________________________________ 51

Anthem Blue Cross of California Final Report of the Routine Survey March 24, 2015

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EXECUTIVE SUMMARY

On August 29, 2013, the California Department of Managed Health Care (the “Department”) notified Anthem Blue Cross (the “Plan”) that its Routine Survey had commenced and requested that the Plan submit information regarding its health care delivery system. The survey team conducted the onsite portion of the survey from November 4, 2013 through November 8, 2013; December 9, 2013 through December 11, 2013; December 16, 2013 through December 19, 2013; and February 10-11, 2014. The review period for the Survey was September 1, 2011 to August 31, 2013.

The Department issued its Preliminary Report to the Plan on September 3, 2014. The Plan had 45 days to file a written statement with the Director describing actions taken to correct any identified deficiency and the results of such action. As a result of the Routine Survey, the Department identified seven deficiencies:

Grievances and Appeals

In Deficiency #1, the Department found that the Plan does not maintain a grievance system that consistently ensures any written or oral expression of dissatisfaction is considered a grievance. Twenty-one percent (21%) of the files reviewed contained expressions of dissatisfaction that were misclassified by the Plan as inquiries rather than grievances, in violation of Section 1368(a)(1) and Rule 1300.68(a)(1). The failure to appropriately identify and resolve matters as grievances denies enrollees significant consumer protections. Further, the Department found that fifty-five percent (55%) of the inquires reviewed contained insufficient documentation to distinguish whether the nature of the enrollee’s call was an inquiry or grievance. The failure to adequately document inquiries renders the Plan unable to ensure oversight and meet its obligation to track and trend grievance data and to detect systemic problems as required by Section 1368(a)(4)(B).

In Deficiency #2, the Department found that in eight percent (8%) of “exempt” grievance files reviewed, the Plan impermissibly processed standard grievances pertaining to coverage disputes, disputed health care services involving medical necessity, and experimental or investigational treatment. The Plan’s processing of the grievances through its exempt grievance process is a clear violation of Section 1368(a)(4)(B) and Rule 1300.68(d)(8).

In Deficiency #3, the Department found that the Plan impermissibly processes standard grievances that are not resolved by the close of the next business day through its exempt grievance process. This is also a clear violation of Section 1368(a)(4)(B) and Rule 1300.68(d)(8). Eighteen percent (18%) of the exempt grievance files reviewed were either incorrectly processed as exempt grievances because they were not resolved by the following business day or the file failed to include sufficient documentation to show that the grievance had been resolved, if at all. Because these files were misclassified as exempt grievances, enrollees did not receive appropriate written acknowledgment and resolution letters through the Plan’s standard grievance process.


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The Plan’s written response to the Preliminary Report provided one combined corrective action plan for Deficiencies #1, 2, and 3. After reviewing the Plan’s response, the Department found that the Plan implemented extensive corrective actions to remedy the deficiencies identified. However, additional time is needed to allow full implementation of the Plan’s corrective actions regarding these deficiencies. File review will be conducted during a Follow-Up Survey to assess the effectiveness of the corrective action plan. Therefore, the Department determined that Deficiencies #1, 2, and 3 have not been corrected.

In Deficiency #4, the Department found that the Plan does not maintain a grievance system that consistently ensures adequate consideration of enrollee grievances and rectification, where appropriate, as required by Rule 1300.68(a)(1). In twenty percent (20%) of the standard grievance files and in eleven percent (11%) of the behavioral health grievance files reviewed, the Plan did not adequately consider, investigate, and rectify the enrollee’s grievance. Numerous files reflected a combination of issues that demonstrated non-compliance with requirements set forth under Sections 1368(a)(1), (4)(A) and (5), Rule 1300.68(a)(1), and Rules 1300.68(d)(1)-(3) and (5).

In its response to the Preliminary Report, the Plan disputed some of the Department’s findings in Deficiency #4 and asked the Department to consider issuing a recommendation in lieu of finding the Plan deficient, given the improvements made in grievance and appeals processing in response to Deficiencies #1, 2, and 3. Where the Plan agreed with the Department’s determinations, it used the deficient files as examples to train its Customer Service staff.

The Department determined that Deficiency #4 has not been corrected. Further, after reviewing the Plan’s response in detail, the Department declined the Plan’s request to issue a recommendation in lieu of a deficiency. File review will be conducted during a Follow-Up Survey to determine if the Plan has implemented corrective action sufficient to bring the Plan into compliance with Sections 1368(a)(1), (4)(A), and (5), Rule 1300.68(a)(1), and Rules 1300.68(d)(1)-(3) and (5).

In Deficiency #5, the Department found that the Plan does not maintain a grievance system that consistently ensures compliance with all acknowledgment letter requirements stated under Section 1368(a)(4)(A)(ii), Section 1368.02(b), Rule 1300.68(b)(3), and Rule 1300.68(d)(1). The Department reviewed behavioral health grievances and found that seventeen percent (17%) of the acknowledgment letters did not comply with one or more of the following requirements:

1. Acknowledgement letter sent within five calendar days as required by Section 1368(a)(4)(A) and Rule 1300.68(d)(1);

2. Required language set forth in an appropriate format as required by Section 1368.02(b); and

3. Linguistic, cultural, and disability needs of the enrollee were addressed as required by Rule 1300.68(b)(3).

In its response to the Preliminary Report, the Plan indicated that it would conduct training and implement auditing to verify the timeliness and appropriateness of acknowledgment letters to correct this deficiency. The Department finds that the Plan


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has implemented corrective actions to remedy the deficiency identified. However, additional time is needed to allow full implementation of the Plan’s corrective actions. File review will be conducted during a Follow-Up Survey to assess the effectiveness of the corrective action plan. Therefore, the Department determined that Deficiency #5 has not been corrected.

Utilization Management

In Deficiency #6, the Department found that the Plan did not consistently include all required information in its written responses that deny, delay, or modify health care service requests by providers based in whole or in part on medical necessity, in accordance with Section 1367.01(h)(4). The Department found a combination of issues in four types of utilization management letters where service requests were denied, delayed, or modified: 1) decisions processed by the Plan, 2) decisions processed by delegated medical groups, 3) behavioral health decisions, and 4) applied behavioral analysis/therapy (ABA). The Department found that the written responses did not consistently include a clear and concise explanation of the reasons for the decision, a description of the criteria or guidelines used, and/or the clinical reasons for the decision.

Fifteen percent (15%) of the utilization management decisions processed by the Plan did not contain a clear and concise explanation of the reasons for the Plan’s decision, and nine percent (9%) did not provide the clinical reasons for decisions regarding medical necessity. Twenty-seven percent (27%) of those processed by delegated medical groups did not include letters that contained a clear and concise explanation for the denial, and seventeen percent (17%) did not provide clinical reasons for the denials. Eighty-seven percent (87%) of the behavioral health utilization management denial decisions reviewed did not include a clear and concise explanation for the denial, and six percent (6%) did not include a clinical reason. Fifty-three percent (53%) of the ABA decisions did not include a clear and concise explanation for the denial, and one-hundred percent (100%) of the decisions reviewed did not include a description of the criteria or guideline used in making the decision.

In response to the Department’s Preliminary Survey Report, the Plan disputed some of the Department’s findings related to the utilization management files processed by the Plan, and along with findings related to the behavioral health utilization management files. The Plan set forth the process it uses to try to ensure that utilization management letters are clear and concise. However, it is unclear whether the Plan’s response, related to the deficient files processed by the Plan, contained an explanation of its current process or whether it implemented a new process to assist it in ensuring utilization management letters are clear and concise.

In its response, the Plan also acknowledged that decisions processed by its delegated medical groups, as well as ABA decisions, were deficient. The Plan provided evidence that has commenced implementation of a corrective action plan to improve and correct this deficiency.

The Department concludes that additional time is needed before the Department can assess the effectiveness of the Plan’s corrective actions related to this deficiency. File review will be conducted during a Follow-Up Survey to assess compliance with Section


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1367.01. Therefore, the Department has determined that Deficiency #6 has not been corrected.

Language Assistance

In Deficiency #7, the Department found that the Plan does not update its assessment of enrollee language needs and enrollee demographic profile at least once every three years following the initial assessment, in violation of the requirements of Rule 1300.67.04(e)(1).

In response to the Preliminary Report, the Plan submitted a corrective action plan. However, the submitted corrective action plan does not provide sufficient proof of correction. The Department will assess the Plan’s corrective action for Deficiency #7 during the Follow-Up Survey.

In addition to deficiencies in Utilization Management and Language Assistance, the Routine Survey discovered widespread systemic failure of the Plan’s Grievance and Appeals Program that negatively impacted likely a large number of enrollees, who were deprived from the full grievance and appeal rights and protections afforded to them under the Knox-Keene Act. The deficiencies cited in this Report will be referred to the Department’s Office of Enforcement for possible disciplinary action.

2013 SURVEY DEFICIENCIES TABLE

# DEFICIENCY STATEMENT

GRIEVANCE AND APPEALS

1 The Plan does not maintain a grievance system that consistently ensures any written or oral expression of dissatisfaction is considered a grievance. Section 1368(a)(1) and Rule 1300.68(a)(1).

Not Corrected

2

The Plan impermissibly processes standard grievances pertaining to coverage disputes, disputed health care services involving medical necessity, and experimental or investigational treatment through its exempt grievance process. Section 1368(a)(4)(B) and Rule 1300.68(d)(8).

Not Corrected

3

The Plan impermissibly processes standard grievances that are not resolved by the close of the next business day through its exempt grievance process. Section 1368(a)(4)(B); Rule 1300.68(a)(4); and Rule 1300.68(d)(8).

Not Corrected


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4

The Plan does not maintain a grievance system that consistently ensures adequate consideration of enrollee grievances and rectification where appropriate. Sections 1368(a)(1), (4)(A) and (5); Rule 1300.68(a)(1); and Rules 1300.68(d)(1)-(3) and (5).

Not Corrected

GRIEVANCES AND APPEALS BEHAVIORAL HEALTH ONLY

5

The Plan does not maintain a grievance system that consistently ensures compliance with all acknowledgment letter requirements. Section 1368(a)(4)(A)(ii); Section 1368.02(b); Rule 1300.68(b)(3); and Rule 1300.68(d)(1).

Not Corrected

UTILIZATION MANAGEMENT

6

For decisions to deny, delay, or modify health care service requests by providers based in whole or in part on medical necessity, the Plan does not consistently include in its written response:

• a clear and concise explanation of the reasons for the decision,

• a description of the criteria or guidelines used, and

• the clinical reasons for the decision. Section 1367.01(f) and Section 1367.01(h)(4).

Not Corrected

LANGUAGE ASSISTANCE

7

The Plan does not update its assessment of enrollee language needs and enrollee demographic profile at least once every three years following the initial assessment. Rule 1300.67.04(e)(1).

Not Corrected


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SURVEY OVERVIEW

The Department evaluates each health care service plan licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975.1 At least once every three years, the Department conducts a Routine Survey of a Plan that covers eight major areas of the Plan’s health care delivery system. The survey includes a review of the procedures for obtaining health services, the procedures for providing authorizations for requested services (utilization management), peer review mechanisms, internal procedures for assuring quality of care, and the overall performance of the Plan in providing health care benefits and meeting the health needs of the subscribers and enrollees in the following areas:

Quality Management – Each plan is required to assess and improve the quality of care it provides to its enrollees.

Grievances and Appeals – Each plan is required to resolve all grievances and appeals in a professional, fair, and expeditious manner.

Access and Availability of Services – Each plan is required to ensure that its services are accessible and available to enrollees throughout its service areas within reasonable timeframes.

Utilization Management – Each plan manages the utilization of services through a variety of cost containment mechanisms while ensuring access and quality care.

Continuity of Care – Each plan is required to ensure that services are furnished in a manner providing continuity and coordination of care, and ready referral of patients to other providers that is consistent with good professional practice.

Access to Emergency Services and Payment – Each plan is required to ensure that emergency services are accessible and available, and that timely authorization mechanisms are provided for medically necessary care.

Prescription Drugs – Each plan that provides prescription drug benefits must maintain an expeditious authorization process for prescriptions and ensure benefit coverage is communicated to enrollees.

Language Assistance – Each plan is required to implement a Language Assistance Program to ensure interpretation and translation services are accessible and available to enrollees.

PLAN BACKGROUND

In 1993, the Plan was granted a license to operate as a health care service plan pursuant to the Knox-Keene Health Care Service Plan Act. In 2004, the Plan 1 The Knox-Keene Act is codified at Health and Safety Code section 1340 et seq. All references to

“Section” are to the Health and Safety Code unless otherwise indicated. The regulations promulgated from the Knox-Keene Act are codified at Title 28 of the California Code of Regulations section 1000 et seq. All references to “Rule” are to Title 28 of the California Code of Regulations unless otherwise indicated.


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restructured its operations and formed a holding company, WellPoint Health Networks Inc., which merged with, and is now a subsidiary of, WellPoint, Inc. The Plan is headquartered in Woodland Hills, California. As of June 30, 2013, the Plan provides health care services to 3,123,015 enrollees. The membership breakdown per program was as follows:

• Commercial: 1,994,203 • Medicare: 268,808 • Medi-Cal: 763,249 • Healthy Families: 96,755

The Plan serves all major counties within California. As of June 30, 2013, the Plan reported that it has 1,429 physicians in contracted Medical Groups, 20,526 physicians in contracted Independent Physician Associations (IPA), and 752 Direct Contract Providers for its Primary Care Providers. Additionally, for specialty services the Plan reported that it has 7,621 providers in contracted Medical Groups, 46,494 providers in contracted IPAs, and 1,105 Direct Contract Specialty Providers. Primary Care, Specialty Provider Medical Groups and IPAs receive capitation payments, whereas the Plan’s Direct Contract Primary Care and Specialty Providers receive payment on a fee-for-service basis. The Plan reported that in 2013 it contracted with a total of 332 hospitals for acute care, with 245 mental health units in these acute care hospitals. In addition, there are 19 freestanding mental health hospitals in its networks.

The Plan delegates utilization management functions to AIM Specialty Health, an affiliate company, Radiant Services, LLC, an affiliate company, American Specialty Health Plans, and Express Scripts, Inc. Express Scripts, Inc. is also delegated as the Plan’s Pharmacy Manager.


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SECTION I: DISCUSSION OF DEFICIENCIES AND CURRENT STATUS

The following details the Department’s preliminary findings, the Plan’s corrective actions and the Department’s findings concerning the Plan’s compliance efforts.

DEFICIENCIES

GRIEVANCES AND APPEALS

Deficiency #1: The Plan does not maintain a grievance system that consistently ensures any written or oral expression of dissatisfaction is considered a grievance.

Statutory/Regulatory Reference(s): Section 1368(a)(1) and Rule 1300.68(a)(1).

Section 1368(a)(1) states, “Every plan shall … [e]stablish and maintain a grievance system approved by the department under which enrollees may submit their grievances to the plan. Each system shall provide reasonable procedures in accordance with department regulations that shall ensure adequate consideration of enrollee grievances and rectification when appropriate.”

Rule 1300.68(a)(1) states, “The grievance system shall be established in writing and provide for procedures that will receive, review and resolve grievances within 30 calendar days of receipt by the plan, or any provider or entity with delegated authority to administer and resolve the plan's grievance system. The following definitions shall apply with respect to the regulations relating to grievance systems: (1) "Grievance" means a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration or appeal made by an enrollee or the enrollee's representative. Where the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance.” [Emphasis added.]

Assessment: The Plan receives phone calls from California members in customer service call centers located in Newbury Park, Denver, Rancho Cordova, Diamond Bar, and Woodland Hills, California. The Customer Service Department is the primary and initial point of contact for the intake of all enrollee complaints and grievances. The Plan provides training for its Customer Care Associates (CSRs) and has modules/resources available for guidance. The Plan’s document titled, “CA Grievances and Appeals Overview,” defines grievances and states, “A grievance is a verbal or written expression of dissatisfaction regarding the Plan and/or provider, including quality of care and service concerns made by a member or the member’s representative.” The document provides guidelines on how to distinguish “grievances” from “inquires” and instructs CSRs to document calls as grievances if they cannot make the distinction. Therefore, CSRs are tasked with accurately distinguishing inquiries from grievances and forwarding all standard grievances to the Plan’s Grievances and Appeals Department for standard processing. The Grievances and Appeals Department then is responsible


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for investigating grievances and providing members with written acknowledgment and resolution notifications within mandated timeframes.

The Department selected a random sample of 82 files from the Plan’s “Pended/Inquiry Log”2 to assess the Plan’s intake process in effectively distinguishing grievances from inquiries. Review of this log revealed two areas of concern: (1) expressions of dissatisfaction are not consistently processed as grievances, and (2) case note documentation is insufficient, making it difficult to discern whether the nature of the call is an inquiry or grievance. A discussion regarding each of these areas is included below.

1. Expressions of Dissatisfaction Not Processed as Grievances

Of the 82 inquiries reviewed, the Department identified 17 cases (21%) where the Plan classified expressions of dissatisfaction as inquiries rather than grievances.3 Therefore, the Plan did not handle these cases as grievances, which would have required the Plan to acknowledge receipt of the grievance, resolve it within 30 days, and provide the enrollee with a written resolution and explanation of the Plan’s decision. Additionally, these resolution letters contain important consumer protection information concerning enrollee’ rights to pursue an Independent Medical Review or complaint review through the Department. In addition, because they were not handled as grievances, these cases were not tracked and trended for the purpose of uncovering systemic problems, thereby providing opportunities for quality improvement. In short, by handling these matters as inquires, enrollees with actual grievances are being deprived of significant consumer protections of the Knox-Keene Act.

Case Examples

• The member called the Plan on September 9, 2013 complaining that she and her husband’s account was in collections for over $11,500 because a participating provider was billing them for services rendered. The CSR contacted the participating provider who told him that the Plan paid for one day of service but not the other. After confirming this information, the CSR advised the member and provider that he would send the claim back to the Claims Department for adjustment to ensure payment for the second day. The Plan ultimately adjusted the claim on October 30, 2013.

• The member called about the denial of a certain medication. She had previously contacted the Plan earlier in the year to obtain authorization, but now the medication was being denied. The member was advised by the CSR that research would be conducted and that the member would be contacted.

• The member repeatedly called the Plan and expressed dissatisfaction because the Plan denied all of her medications as the Plan’s records showed that the member had met her lifetime maximum. The call documentation indicates the member was upset and yelling during some of the phone calls. It also indicates

2 The 82 files randomly-selected from the “Pended/Inquiry Log” are comprised of inquiries from all four of

the Plan operated call centers. 3 See TABLE 1: Inquiries.


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that the member informed the Plan that she would die without her medication and that she was previously told by a supervisor that the lifetime maximum had not been met. Despite these facts, the Plan processed the member’s numerous clear expressions of dissatisfaction as inquiries rather than as grievances. Further, during one of these phone calls, the member was advised the account would be audited and to allow 45 days, not 30 days for a resolution as mandated by Rule 1300.68(d)(3) or in the case of urgent grievances three days for a disposition or status under Section 1368.01(b). Documentation from one phone call indicated that this issue had been ongoing for six months.

After an investigation, the Plan determined that the lifetime maximum had not been met. Subsequent notes indicate that the Plan continued to perform overrides so that member could obtain the medications.

In another phone call over a month later, the Plan had still not corrected the problem. Notes documented by the CSR state, "Member upset, needs [override] for [two medications], she said cannot go on like this, not acceptable.” The Plan again failed to initiate a grievance and instead informed the member that he/she, “can check on this [and follow-up], but may not be today as my manager is out of town, if member need RX she can pay upfront but not guarantee [override] can be issued.”

• The member's spouse called on behalf of the member to discuss how a particular claim was processed. The member had received services from an out-of-state provider through the Blue Cross Blue Card Program. The member felt that the service should have been treated as a preventive mammogram and thus a higher level of coverage should have applied. The Plan indicated that the member needed to contact the hospital to discuss the coding. Because these issues involve a coverage determination, the case should have been classified as a grievance rather than an inquiry.

The Department’s review of the “Inquiry Log” discovered numerous cases that demonstrate the Plan’s failure to identify clear expressions of dissatisfaction as grievances and process them as such. Also noteworthy, is the Department’s observation that the Plan inconsistently handles calls that are similar in nature by classifying some as inquiries, and alternately others as grievances. This becomes especially apparent for cases related to claims processing. Although the cases described above include several examples of claims related calls processed as “inquiries,” the two examples below were classified as “exempt grievances.”

Case Examples

Case notes indicate that the member called to inquire about certain tagged claims. The CSR advised the member that originally claims should have been sent to the administrator of the behavioral health benefits.

• The member contacted the Plan based on the member’s belief that a particular claim was processed incorrectly.


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Although these case examples are similar in nature to those claims related calls reviewed by the Department that were classified as inquiries, these calls were categorized as exempt grievances. Therefore, despite the training modules and tools available for CSRs to access, it appears that the calls are inconsistently processed. Interviews with Plan staff during the Survey revealed a lack of monitoring to ensure that CSRs consistently and accurately distinguish inquiries from grievances.

2. Insufficient Documentation in the Inquiry Log

In addition to failing to process clear expressions of dissatisfaction through the Plan’s grievance system, the Department identified 45 inquiries (55%) from those same 82 inquiries that contained insufficient documentation by CSRs. Therefore, the Department was unable to distinguish whether the nature of the enrollee’s call was an inquiry or a grievance. This represents a significant number of files categorized by the Plan as inquiries that may have been appropriate for grievance handling.

During the Survey, Plan representatives reviewed many of the 45 files at issue and were similarly unable to elaborate on the purpose of the enrollee’s call or the Plan’s resolution. The Plan’s current logging system does not allow the CSR to capture whether the enrollee’s issue should be classified and handled as either an inquiry or grievance. For each case reviewed, the Plan provided a cover page (screenshot) that included the member’s basic information (name, date of birth, plan type, benefits, etc.) and a drop down button that displayed one to two words describing the purpose of the call (claims, benefits, etc.).

A significant number of the 45 inquiries related to claims processed by the Plan. Due to insufficient documentation in file, the Department was unable to discern whether the enrollee was calling simply to seek information on how a claim was processed, or was actually calling to dispute the claim.

Case Examples

• The documentation provided for this particular case indicated the member was calling to discuss a claim that the Plan recently processed. The Plan then sent the claim for reprocessing. However, there was no further documentation capturing details regarding the nature of the call.

• A single page screenshot indicated that the member was calling about a claims issue. However, there was no further documentation by the CSR elaborating on the details surrounding the nature of the call.

• A single page screenshot indicated that the member was calling about a claim recently processed by the Plan. The CSR’s notes documented that the member was an HMO member and needed to get authorization from the medical group for the services on a claim. Case notes further indicated that the CSR contacted the medical group on behalf of the member and obtained the authorization and thus adjusted the claim. However, there was insufficient documentation to determine whether the actions taken by the CSR were due to an inquiry or the


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enrollee’s expression of dissatisfaction. If the latter was the case, then the file should have been processed as a grievance.

In addition to the three examples described above, the Department provided the Plan with a list of the additional 42 inquiries that similarly included only cursory documentation in the file consisting of either a single page screenshot and/or case notes merely indicating that the particular claim was sent for reprocessing.

Section 1368(a) requires the Plan to establish and maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. Rule 1300.68(a)(1) defines a grievance as “a written or oral expression of dissatisfaction” and “[w]here the Plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance.”

The Department’s review of the Plan’s “Pended/Inquiry Log” revealed two areas of concern: 1) Expressions of dissatisfaction are not consistently processed as grievances (21% non-compliance rate), and 2) case note documentation in the log is insufficient, making it difficult to discern whether the nature of the call is an inquiry or grievance (55% non-compliance rate). Without being able to accurately and consistently distinguish inquiries from grievances, the Plan cannot ensure that all grievances receive adequate consideration, investigation, and resolution as required by Section 1368(a)(1) or that all grievances are tracked and trended for the purpose of uncovering systemic problems as required by Section 1368(a)(4)(B). While CSRs are trained and have resources available to them, effective monitoring does not occur as issues of a similar nature are processed inconsistently by CSRs, some being categorized as inquiries while others as grievances. Therefore, the Department finds the Plan in violation of these statutory and regulatory requirements.

TABLE 1 Inquiries

FILE TYPE

NUMBER OF

FILES ELEMENT COMPLIANT DEFICIENT UNKNOWN4

Inquiries 82

Any written or oral expression of dissatisfaction is identified and processed as a grievance

20 (24%) 17 (21%) 45 (55%)

4 Unable to measure compliance with element due to insufficient documentation contained in inquiry case

summary notes.


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Plan’s Compliance Effort: Within 45 days following notice of a deficiency, the Plan was required to file a written statement with the Department signed by an officer of the Plan, describing any actions that have been taken to correct the deficiency.

1. The Plan undertook the following efforts to improve its process to ensure it correctly identifies and processes grievances.

In response to the deficiencies identified by the Department related to its internal processes, inconsistent associate behaviors and errors, system limitations, insufficient reporting and other areas for process improvement, the Plan conducted a review of its Customer Service Operations, member call handling and case documentation. As a result, Customer Service leadership implemented robust corrective action in the following areas:

• Executive level advisory meetings with Compliance, Grievances and Appeals, and Legal leadership

• Significant personnel acquisitions and development • Enhanced internal auditing standards • Comprehensive reporting review and improved reports • Pilot testing of new approaches • Process and policy review • Technology upgrades • Newly revised training and assessment processes • Legacy system upgrades

Training

The Plan examined the existing grievances and appeals training in an effort to evaluate its content, delivery methods, and overall training effectiveness, as well as implement a new grievances and appeals training, training assessment and certification process. The Plan assembled a team that spent two months analyzing the existing training, identifying gaps in instruction, as well as missing or outdated content. The team concluded a new Annual Grievances and Appeals Training reconstruction process was needed to achieve the following goals:

• Ensure each CSR has the ability to readily identify whether a call is an inquiry or a grievance.

• Determine the classification of grievance when processing and documenting a call.

• Emphasize the positive impacts proper grievance identification and processing has for members.

• Promote the importance that proper grievance identification and processing has for the company.

• Provide the proper job aids, talking points and Quick Reference Guides to the CSRs allowing them to perform their job duties more accurately and efficiently.

• Improve the curriculum delivery method and improve material and content retention.


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The team then spent four months reconstructing the Annual Grievances and Appeals Training that every CSR is required to complete. Each CSR is required to attend a three-hour training and complete a Knowledge Assessment Exam to ensure retention of training content. CSRs must pass this exam with a minimum score of 80%. As of November 20, 2014, 99% of CSRs had completed the training.

Auditing

In addition to its existing monthly audits, the Plan also developed an auditing process focused specifically on the identification and proper documentation of One Day/Exempt Grievances. The Plan implemented the new audit process on November 1, 2014.

On November 5, 2014, the Plan implemented a Close of Call Script in an attempt to ensure that CSRs correctly identify inquiries, exempt grievances, and standard grievances. The Close of Call Script Pilot was designed to provide CSRs with a series of questions at the conclusion of every call to ensure that they are closing the call properly, addressing any additional concerns that the member may have, and properly identifying any potential indications or expressions of dissatisfaction. The Plan reported it would begin auditing the Close of Call Script elements on December 5, 2014.

Monitoring

On August 1, 2014, Customer Service Operations implemented an enhanced One-Day Grievance Reporting Process to monitor and track open and pending activity on a daily basis. The enhanced reporting process now includes:

• The name and ID of the CSR, the Manager of the CSR, and the current owner of the exempt/one day grievance

• New fields to clearly identify the age of each grievance • Aging thresholds to alert a CSR when a one day grievance is reaching the end of

the next business day and must be moved to the standard grievance process • Aging Reports to allow easy access to the age of each case • Tracking of exempt/one day grievances that are converted to standard

grievances • A new volume report

Technology Upgrades for Better Detection of Grievances

The Plan enhanced its inquiry tracking system by adding two new fields: one to categorize the purpose for the call and another to indicate whether the member is satisfied. This enhancement would allow Customer Service Operations to run additional reports to easily identify and review any inquiries related to complaints and customer dissatisfaction. This improvement was implemented on October 18, 2014.

On November 1, 2014, the Plan also began a four-month pilot testing of a speech analytics software to assist in identifying grievances and improve member satisfaction. The software monitors phone calls in real-time for terms and phrases to alert the CSR to acknowledge the call as a one-day grievance. The software will also record and


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transcribe member phone calls, and then analyze the data and provide detailed reports and trending summaries to the Plan the following business day.

2. Failure to sufficiently document inquiry logs to discern whether the call is an inquiry or a grievance.

The Plan reviewed its existing training and found that it did not directly address the importance of proper call documentation practices and the possible impacts that incomplete documentation may have. As part of its new Annual Grievance and Appeals Training, as described above, the Plan incorporated instructions for proper documentation of grievances and interactions with members. The Plan now conducts audits to assess thorough case documentation.

Final Report Deficiency Status: Not Corrected

The Department finds that the Plan implemented extensive corrective actions to remedy the deficiency identified. However, additional time is necessary to allow for full implementation and to assess the effectiveness of the Plan’s corrective actions. Therefore, the Department has determined that this deficiency has not been corrected. The Department will verify implementation of the Plan’s corrective action and conduct file review during a Follow-Up Survey to assess the effectiveness of the Plan’s corrective action.

Deficiency #2: The Plan impermissibly processes standard grievances

pertaining to coverage disputes, disputed health care services involving medical necessity, and experimental or investigational treatment through its exempt grievance process.

Statutory/Regulatory Reference(s): Section 1368(a)(4)(B) and Rule 1300.68(d)(8).

Section 1368(a)(4)(B) states, “Grievances received by telephone, by facsimile, by e-mail, or online through the plan’s Internet Web site pursuant to Section 1368.015, that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt are exempt from the requirements of subparagraph (A) [the obligation to send a written acknowledgment to the member] and paragraph (5) [the obligation to send a written response/resolution to the member]. The plan shall maintain a log of all these grievances. The log shall be periodically reviewed by the plan …” [Emphasis added.]

Rule 1300.68(d)(8) states, “Grievances received over the telephone that are not coverage disputes, disputed health care services involving medical necessity or experimental or investigational treatment, and that are resolved by the close of the next business day, are exempt from the requirement to send a written acknowledgment and response. The plan shall maintain a log of all such grievances containing the date of the call, the name of the complainant, member identification number, nature of the


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grievance, nature of resolution, and the plan representative’s name who took the call and resolved the grievance. The information contained in this log shall be periodically reviewed by the plan as set forth in Subsection (b).” [Emphasis added.]

Assessment: The Plan document, “One Day Grievance Guidelines,” provides CSRs with guidelines for processing one day (exempt) grievances. It is consistent with the requirements of Section 1368(a)(4)(B) and Rule 1300.68(d)(8) and specifies the following exclusions to one day grievances stating, “One day grievances cannot include issues regarding the following: Medical necessity, Experimental or investigational treatments, Coverage disputes …” [Emphasis in original.] Additional guidelines instruct CSRs to process all grievances in the aforementioned categories as “Urgent/Expedited” or “Standard/Priority.” Therefore, similar to being able to make the distinction between inquiries and grievances5, CSRs must also correctly discern grievances related to medical necessity, experimental or investigational treatment, and coverage disputes, in order to forward them to the Grievance and Appeal Department for appropriate handling. Errors in judgment from CSRs could lead to the mishandling of complaints, resulting in inaccurate, incomplete, and underreported data from the Grievance and Appeal Department.

The Department reviewed a random sample of 100 exempt grievances6 to assess the Plan’s process in effectively distinguishing exempt grievances from standard grievances. In eight of 100 files (8%), CSRs incorrectly processed grievances pertaining to medically necessity, experimental or investigation treatment, and/or coverage disputes, as exempt grievances7. These grievances, therefore, did not receive appropriate written acknowledgment and resolution of the grievance through the Plan’s Grievances and Appeals Department.

Case Examples

Full Service Exempt Grievances

• Case notes indicate that the caller requested a particular brand name of medication. The CSR’s notes state, “Caller faxed a grievance form … advised that the Plan prefers generics … and record does not show she has taken any in past 6 months … member … on prior insurance … has been taking this RX for over a year … advised member she can follow through with the generic ... and if not work within timeframe then to have doctor resubmit prior authorization ... also faxed enrollee a grievance form ... member not sure if she will file a grievance.” The Plan’s CSR advised the member of a denial based on coverage and medical necessity related issues without knowing whether there could have been a medical basis for her taking the brand name medication previously.

5 See Deficiency #1. 6 The 100 exempt grievances randomly-selected are comprised of 78 full service and 22 behavioral

health grievances. 7 See TABLE 2: Exempt Grievances.


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• The CSR’s case notes state, “Member is calling about her shingles shot. Per the member she was told she could get the medication from the pharmacy and have it administered in the doctor’s office … advised it won't be covered if she picked it up from the pharmacy ... per the member she will just tell the doctor to put it on his bill ... told that would be between her and the doctor ... but if we get the pharmacy claim we won't pay for the services.”

In an interview, Plan staff acknowledged that this case was not appropriate for processing as an exempt grievance because it involved a coverage issue.

• The member requested the CSR locate a spine specialist in the Palo Alto area. After being unable to locate a specialist in the member’s area, the member was then advised by the CSR to file an appeal to request an out-of network provider.

Behavioral Health Exempt Grievances

• The member contacted the Plan to request an override for a controlled substance. The CSR contacted the Plan’s Pharmacy Department who then contacted the Plan pharmacy and obtained a one-time override authorization for the prescription. The CSR advised the member to go to the local pharmacy to have the prescription refilled.

However, the request for a prescription override requires a medical necessity determination. Rather than sending the member’s request through the standard grievance process to determine if the prescription was medically indicated, the Plan’s CSR resolved the issue through a one-time override. Therefore, this case was not appropriate for exempt grievance classification or processing.

• The member contacted the Plan requesting to see a non-contracted mental health provider for post-traumatic stress disorder. The request had been previously denied. The member was informed by the CSR that the provider was not contracted with the Plan, and therefore was not available for referral unless there were no available in-network providers within a 50 miles radius. The CSR offered to assist the member with the filing of an appeal. However, the member did not wish to file an appeal and asked to speak to a supervisor. The call was disconnected while the CSR was transferring the call, but the CSR was able to contact the member again and indicated that the medical group would be contacted in an attempt to resolve the issue. The case was closed two days later.

The member’s request to see an out-of-network provider involved a coverage dispute, and therefore was not appropriate for exempt grievance processing.

Section 1368(a)(4)(B) and Rule 1300.68(d)(8) allows only grievances received by telephone, by facsimile, by e-mail, or online through the Plan’s Internet Web site that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day to be exempt from sending written acknowledgment and response/resolution to the member. However, the Department’s review of 100 exempt grievances revealed a number of cases (8% non-compliance rate) pertaining to medical necessity and


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coverage disputes misclassified by CSRs as exempt grievances and handled as such. Moreover, there was no indication of monitoring processes by the Plan to ensure that all grievances pertaining to coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment received in the Customer Service Department were forwarded consistently by CSRs to the Grievances and Appeals Department for proper notification, investigation, and resolution. Therefore, the Department finds the Plan in violation of these statutory and regulatory requirements.

TABLE 2 Exempt Grievances

FILE TYPE NUMBER

OF FILES

ELEMENT COMPLIANT DEFICIENT

Exempt Grievances 100

Grievances pertaining to coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment are not processed as exempt grievances

92 (92%) 8 (8%)


The Plan’s response addressed Deficiencies #1, 2 and 3 together. Refer to the Plan’s Compliance Effort in Deficiency #1 for details.


The Department finds that the Plan has implemented extensive corrective actions to remedy the deficiency identified. However, additional time is necessary to allow for full implementation and to assess the effectiveness of the Plan’s corrective actions. Therefore, the Department has determined that this deficiency has not been corrected. The Department will verify implementation of the Plan’s corrective action and conduct file review during a Follow-Up Survey to assess the effectiveness of the Plan’s corrective action.

Deficiency #3: The Plan impermissibly processes standard grievances that are

not resolved by the close of the next business day through its exempt grievance process.


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Statutory/Regulatory Reference(s): Section 1368(a)(4)(B); Rule 1300.68(a)(4); and Rule 1300.68(d)(8).

Section 1368(a)(4)(B) states, “Grievances received by telephone, by facsimile, by e-mail, or online through the plan’s Internet Web site pursuant to Section 1368.015, that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt are exempt from the requirements of subparagraph (A) [the obligation to send a written acknowledgment to the member] and paragraph (5) [the obligation to send a written response/resolution to the member]. The plan shall maintain a log of all these grievances. The log shall be periodically reviewed by the plan and shall include the following information for each complaint:

(i) The date of the call. (ii) The name of the complainant. (iii) The complainant’s member identification number. (iv) The nature of the grievance. (v) The nature of the resolution. (vi) The name of the plan representative who took the call and resolved the

grievance.” [Emphasis added.]

Rule 1300.68(a)(4) states, “‘Resolved’ means that the grievance has reached final conclusion with respect to the enrollee’s submitted grievance, and there are no pending enrollee appeals within the plan’s grievance system, including entities with delegated authority.”

Rule 1300.68(d)(8) states, “Grievances received over the telephone that are not coverage disputes, disputed health care services involving medical necessity or experimental or investigational treatment, and that are resolved by the close of the next business day, are exempt from the requirement to send a written acknowledgment and response. The plan shall maintain a log of all such grievances containing the date of the call, the name of the complainant, member identification number, nature of the grievance, nature of resolution, and the plan representative’s name who took the call and resolved the grievance. The information contained in this log shall be periodically reviewed by the plan as set forth in Subsection (b).” [Emphasis added.]

Assessment: Two Plan documents, “One Day Grievance Guidelines,” and “CA Grievances and Appeals Overview,” provide CSRs with guidelines for processing one day (exempt) grievances. The “CA Grievances and Appeals Overview,” is consistent with the requirements of Section 1368(a)(4)(B) and states, “If the issue is not resolved by the next business day, it must automatically be handled as a standard grievance, and the Service associate must complete the Grievance and Appeal form and send the appropriate acknowledgment letter.” Therefore, CSRs are responsible for forwarding all grievances that are not resolved within one business day onto the Grievances and Appeals Department for standard processing. Failure to do so could lead to the mishandling of more complex complaints that take longer to resolve by CSRs, resulting in inaccurate, incomplete, and underreported data from the Grievances and Appeals Department.


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The Department reviewed a random sample of 100 exempt grievances8 to assess the Plan’s process in effectively distinguishing exempt grievances from standard grievances. In 18 of 100 files (18%), the Plan either incorrectly processed grievances as exempt that were not resolved by the following business or failed to include sufficient documentation to support how the grievance had been resolved, if at all9. Because these files had been misclassified as exempt grievances, enrollees did not receive appropriate written acknowledgment and resolution through the Plan’s standard grievance process.

Case Examples

Full Service Exempt Grievances

• The Plan received and closed this grievance on the same day, March 15, 2013. However, there was no documentation indicating when the grievance was resolved.

The member was upset about an issue that had remained unresolved since January 13, 2013. Case documentation stated, “…this request was never worked on.” The member indicated he should not have had any lapses in coverage because he had a [different type of plan]. The member additionally raised a quality of service issue based on the Plan’s inability to resolve the matter in a timely manner. Based on the documentation in file, no evidence of resolution could be determined. Therefore, the Department requested that the Plan conduct an investigation on the matter. As a result, the Plan’s response stated:

Closed as a one day grievance as appeal/request denied. The member was upset the issue was ongoing since January but on same day per inquiry the same CSR routed the tracking for the plan to be changed [and] it was done within 4 days.

Thus, without further inquiry by the Department, the Plan’s file did not include documentation to substantiate resolution of the grievance. Nevertheless, the Plan’s response confirmed that the issue was not resolved by the following business day, but instead four days later and, therefore, did not meet the threshold for exempt grievance processing.

• The Plan received and closed this grievance on the same day, July 9, 2013. However, there was no documentation indicating when the grievance was resolved.

The member expressed dissatisfaction with his HMO and indicated that he was not comfortable working with his dentist as he believed the dentist to be fraudulently reading dental disclaimers. However, there was no documentation to indicate that a follow-up had been conducted to investigate and resolve the issue. Therefore, without any indication of resolution, the Department was unable

8 The random sample of 100 Plan identified exempt grievances is comprised of 78 full service and 22

behavioral health grievances. 9 See TABLE 3: Exempt Grievances.


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determine whether the case was resolved by the following business day thereby meeting the threshold for exempt grievance handling.

• In four cases, the Department was unable to determine neither the nature of the enrollees’ grievances nor the resolutions.

• The Plan received the grievance on February 11, 2013 and resolved it on October 9, 2013, eight months later. The member contacted the Plan requesting to speak to a particular Plan representative. The representative who had taken the call advised the member that the requested representative would give her a call back. The Department was unable to determine from the file what follow-up, if any, had occurred thereafter. Therefore, the Department requested that Plan conduct an investigation. As a result, the Plan’s response stated:

This call was taken on 2/11/13 by [Customer Service Representative #1] and [Customer Service Manager]. The CSR sent a message to the requested [Customer Service Representative #2] who handled the call on, 1/24/2013 per IQT [Number] That rep was working on claim that we denied as the medical group’s responsibility.

The CSR worked on this issue until 2/19/13. This issue was not resolved in one day. The notes indicated that the medical group called back and informed us that they believed the claim was the Plan's responsibility to pay:

Claim was just recently resolved on 10/9/13 where Anthem paid the claim since the services were out of area for the member. The member was admitted to Hospital on 10/19/12. There was confusion because the member's medical group was changed on the date the member went inpatient, 10/19/12.

The Plan’s response confirmed that the issue was not resolved by the following business day, and therefore did not meet the threshold for exempt grievance processing.

• The Plan received the grievance on October 10, 2012 and closed it on October 12, 2012. The member was requesting to see a spine specialist in a certain geographic area. The Plan’s representative attempted to assist the member with locating a specialist but was unable to do so as there were no spine specialists within the member’s geographic area. The CSR advised the member to file an appeal to request authorization to see an out-of-network provider. The Department requested that the Plan provide further documentation regarding this case. As a result, the Plan’s response stated:

The member called on 10/10/12 and the issue was not closed until 10/12/12. HMO member wanted a referral to see specialist. Member did not want to file an appeal they just wanted Anthem to allow him to see a provider outside of his medical group as the request had been previously denied. The CSR advised the member that the


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Appeals process was the correct method for resolving this issue. The member demanded to speak with a Supervisor but was disconnected as the CSR was going to transfer the caller. The CSR did call the member back and was also working with the Medical Group to see if they could resolve the issue.

Therefore, the Plan’s response confirmed that the issue was not resolved by the following business day. Moreover, once the CSR determined that there were no in-network providers available to the member, and that the case could not have been resolved by the following day, the file should have been forwarded to the Grievances and Appeals Department for standard grievance processing to receive appropriate written acknowledgement and resolution.

Behavioral Health Exempt Grievances

• The Plan received the grievance on April 25, 2013 but there was no indication in the file as to how or when the grievance was resolved. The member contacted the Plan regarding a denied prescription claim. Case notes indicate that the call was transferred to the Plan’s pharmacy. The Plan was unable to provide the Department with further information regarding the sequence of events that occurred once the member was transferred. Therefore, there was no documentation in the file to indicate if any follow-up with the Pharmacy had occurred or confirmation that it resolved the enrollee’s grievance. Upon inquiry by the Department, the Plan indicated that some CSRs may consider a transfer to the Plan Pharmacy or another Plan Department as a form of “resolution” and then classify the case as a one-day grievance. However, under Rule 1300.68(a)(4), a grievance is resolved once it has “reached a final conclusion with respect to the enrollee's submitted grievance, and there are no pending enrollee appeals within the plan's grievance system.”

The Plan received the grievance on May 30, 2013 with no indication as to how or when it was resolved. Documentation in the file states that the grievance was placed on hold, indicating that the case was not appropriate for exempt grievance handling from the onset. The member had contacted the Plan by telephone to inquire about and dispute a prescription claim. There was no further information in the file to determine the nature of the resolution. Nevertheless, the issue was not resolved by the following business day and appears to also be related to a coverage issue. Therefore, this file did not meet the threshold for exempt grievance processing.

Section 1368(a)(4)(B) and Rule 1300.68(d)(8) indicate that grievances received by telephone, by facsimile, by e-mail, or online through the Plan’s Internet Web site are exempt from sending written acknowledgment and response/resolution to the member only if they are resolved by the next business day. Further, Rule 1300.68(a)(4) provides that a grievance is resolved once it has “reached a final conclusion with respect to the enrollee's submitted grievance, and there are no pending enrollee appeals within the plan's grievance system.” However, the Department’s review of 100 exempt grievances identified 18 cases that were not resolved within one business day. Therefore, 18% of


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these files did not meet the standard for exempt grievance processing. These cases represent potentially more complex issues that take longer than one business day to resolve, and therefore would benefit from standard grievance processing, which includes formal notification, investigation, and handling. Further, some files did not include sufficient documentation to capture either the nature of the grievance or resolution. Therefore, the Department finds the Plan in violation of these statutory and regulatory requirements.

TABLE 3 Exempt Grievances

FILE TYPE NUMBER

OF FILES


Exempt Grievances 100

Resolved by the following business day and nature of the resolution is captured

82 (82%) 18 (18%)


The Plan’s response addressed Deficiencies #1, 2 and 3 together. Refer to the Plan’s Compliance Effort in Deficiency #1 for details.


The Department finds that the Plan has implemented extensive corrective actions to remedy the deficiency identified. However, additional time is necessary to allow for full implementation and to assess the effectiveness of the Plan’s corrective actions. Therefore, the Department has determined that this deficiency has not been corrected. The Department will verify implementation of the Plan’s corrective action and conduct file review during a Follow-Up Survey to assess the effectiveness of the Plan’s corrective action.

Deficiency #4: The Plan does not maintain a grievance system that consistently

ensures adequate consideration of enrollee grievances and rectification where appropriate.

Statutory/Regulatory Reference(s): Sections 1368(a)(1), (4)(A) and (5); Rule 1300.68(a)(1); and Rules 1300.68(d)(1)-(3) and (5).

Sections 1368(a)(1), (4)(A) and (5) state, “Every plan shall do all of the following: (1) Establish and maintain a grievance system approved by the department under which enrollees may submit their grievances to the plan. Each system shall provide


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reasonable procedures in accordance with department regulations that shall ensure adequate consideration of enrollee grievances and rectification when appropriate.

(4)(A) Provide for a written acknowledgment within five calendar days of the receipt of a grievance, except as noted in subparagraph (B).

(5) Provide subscribers and enrollees with written responses to grievances, with a clear and concise explanation of the reasons for the plan’s response. For grievances involving the delay, denial, or modification of health care services, the plan response shall describe the criteria used and the clinical reasons for its decision, including all criteria and clinical reasons related to medical necessity. If a plan, or one of its contracting providers, issues a decision delaying, denying, or modifying health care services based in whole or in part on a finding that the proposed health care services are not a covered benefit under the contract that applies to the enrollee, the decision shall clearly specify the provisions in the contract that exclude that coverage.” [Emphasis added.]

Rule 1300.68(a)(1) states, “The grievance system shall be established in writing and provide for procedures that will receive, review and resolve grievances within 30 calendar days of receipt by the plan, or any provider or entity with delegated authority to administer and resolve the plan's grievance system. The following definitions shall apply with respect to the regulations relating to grievance systems: (1) "Grievance" means a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, and shall include a complaint, dispute, request for reconsideration or appeal made by an enrollee or the enrollee's representative. Where the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance.” [Emphasis added.] Rules 1300.68(d)(1)-(3) and (5) state, “The plan shall respond to grievances as follows: (1) A grievance system shall provide for a written acknowledgment within five (5) calendar days of receipt, except as noted in subsection (d)(8). The acknowledgment will advise the complainant that the grievance has been received, the date of receipt, and provide the name of the plan representative, telephone number and address of the plan representative who may be contacted about the grievance. (2) The grievance system shall provide for a prompt review of grievances by the management or supervisory staff responsible for the services or operations which are the subject of the grievance. (3) The plan's resolution, containing a written response to the grievance shall be sent to the complainant within thirty (30) calendar days of receipt, except as noted in Subsection (d)(8). The written response shall contain a clear and concise explanation of the plan's decision. Nothing in this regulation requires a plan to disclose information to the grievant that is otherwise confidential or privileged by law. (5) Plan responses to grievances involving a determination that the requested service is not a covered benefit shall specify the provision in the contract, evidence of coverage or member handbook that excludes the service. The response shall either identify the document and page where the provision is found, direct the grievant to the applicable section of the contract containing the provision, or provide a copy of the provision and explain in clear and concise language how the exclusion applied to the specific health care service or benefit requested by the enrollee.” [Emphasis added.]


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Assessment: Health plans are required to establish and maintain a grievance system whereby enrollees can submit their grievances to the Plan, and the Plan will perform adequate consideration and rectification of the grievances as appropriate. It is essential that the Plan give adequate consideration of enrollee grievances in order to rectify previous decisions and ensure that enrollees are appropriately receiving the benefits to which they are entitled. The grievance system is also a crucial tool and valuable mechanism for the Plan to capture data regarding enrollee complaints for tracking and trending to then detect systemic issues that might not otherwise be uncovered through other internal monitoring systems. Therefore, without a robust grievance system in place to ensure the accurate and expeditious identification of enrollee concerns, and thorough investigation of all issues in question, the Plan cannot appropriately resolve grievances to effect opportunities for quality improvement.

The Department conducted separate assessments of the Plan’s full service and behavioral health service grievances.

I. Full Service

The Department conducted an in-depth review of a random sample of 94 standard grievance and appeal files to evaluate the Plan’s grievance system for processing enrollee complaints. In 19 of 94 files (20%), the Plan did not conduct adequate consideration, investigation, and rectification of enrollee grievances10. Numerous files reflected a combination of problematic issues, demonstrating non-compliance with various requirements set forth under Section 1368(a) and Rule 1300.68(a) and (d). Due to the multitude and complexity of issues discovered within individual grievances, the Department identified several patterns of non-compliance that were particularly striking. These areas of concern are listed below and case examples are provided for each category. All examples, however, represent the Plan’s inability to fulfill its overall obligation to maintain a grievance system that consistently ensures adequate consideration and rectification of enrollee grievances. The areas of concern are identified as follows:

1) The Plan does not adequately consider clear, sometimes repeated, expressions of dissatisfaction as grievances, and therefore fails to promptly process them in a timely manner.

2) The Plan does not adequately consider and resolve all enrollee grievances, whether a single issue or multiple issues are raised.

3) The Plan does not perform a thorough investigation of enrollee grievances to ensure appropriate resolution.

4) The Plan’s written responses to enrollees do not contain a clear and concise explanation of the resolution, indicating inadequate consideration of the grievances.

10 See TABLE 4: Standard Grievances and Appeals (Full Service).


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1. The Plan does not adequately consider clear, sometimes repeated, expressions of dissatisfaction as grievances, and therefore fails to promptly process them in a timely manner.

The Department found that the Plan generally complied with the requirements set forth by Section 1368(a)(4)(A) and Rule 1300.68(d)(1) and (3) regarding the timeliness of written acknowledgment and resolution to the enrollee. However, two files demonstrate egregious examples of the Plan’s failure to comply with these provisions, as a result of the Plan’s inability to promptly identify the enrollee’s expression of dissatisfaction as a grievance.

Case Examples

• In this case, almost five months elapsed before the Plan fully acknowledged, considered, investigated, and resolved an enrollee’s grievance concerning coverage of dental and health care services to treat injuries to her lips, jaw and teeth resulting from a fall. Despite the enrollee’s numerous letters (many containing copies of the original letters mailed), and phone calls, it took almost five months for the Plan to acknowledge the enrollee’s repeated expressions of dissatisfaction, consider it a grievance, and process it as such.

The details of this case represent a significant concern regarding the Plan’s untimely delay in classifying an enrollee’s clear expression of dissatisfaction as a grievance and processing it through the grievance system. The Department further notes the failure of the Plan to provide the requested, relevant Evidence of Coverage (EOC) provisions regarding coverage. This is in violation of Rule 1300.68(d)(5) which states, “Plan responses to grievances involving a determination that the requested service is not a covered benefit shall specify the provision in contract, evidence of coverage or member handbook that excludes the service. The response shall either identify the document and page where the provision is found, direct the grievant to the applicable section of the contract containing the provision, or provide a copy of the provision and explain in clear concise language how the exclusion applied to the specific health care service or benefit requested by the enrollee.”

• For a period of almost three months, the Plan did not consider the enrollee’s letter requesting a premium refund and several subsequent phone calls related to the request as expressions of dissatisfaction. After three months and several phone calls, the Plan finally acknowledged and processed the enrollee’s request as a grievance. The Plan’s resolution letter explained the couple’s health plans were cancelled effective October 1, 2012 and that they were enrolled with an effective date of December 1, 2012 in a different plan. In addition, the Plan’s resolution letter did not address the added concern regarding a recurring HIPAA authorization issue that arose every time the wife had called to follow-up on her original letter.

2. The Plan does not adequately consider and resolve all enrollee grievances, whether a single issue or multiple issues are raised.


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Case Examples

• The enrollee initiated a telephone grievance regarding the medical group’s denial of her request for a referral to a lactation consultant. She explained that she had contacted her primary care physician (PCP) who denied the request and informed her that she should have asked for the referral prior to discharge from the hospital. The resolution letter indicated that the Plan had contacted the medical group who informed the Plan that there was no denial on file. However, the Plan’s response did not address the enrollee’s continued need for the specialist referral or provide her with further direction on how to obtain it. Contrary to Section 1368(a)(5), which requires the Plan’s written response to grievances to contain a clear and concise explanation of the reasons, the Plan’s resolution letter appears to be a form letter that does not specifically address the enrollee’s request to see a lactation consultant. Despite the fact that the enrollee clearly indicated that she had already contacted her PCP for a referral, the Plan’s resolution letter referenced the general EOC provisions regarding referrals and the requirement that all care be approved by the medical group and PCP. These provisions merely inform the enrollee that medical care must be provided and authorized by the medical group to avoid denials of claim due to lack of authorization. The only document in the file indicating that the Plan had responded to the enrollee’s referral request was an authorization from the enrollee’s medical group, dated December 12, 2012, for a referral to a certain hospital for a new patient visit to address the diagnosis of mastodynia (breast pain). However, this authorization occurred nearly one month after the Plan’s November 15, 2012 resolution letter.

• An enrollee’s daughter filed a written grievance describing the Plan’s multiple issues including refusal to pay her mother’s claims, poor customer service received when inquiring about the unpaid claims, and inadequate record keeping and storage of the power of attorney form she had submitted to the Plan several years ago. The daughter complained of the length of a phone call (over an hour), the numerous times she was re-routed and misdirected to various telephone numbers, and refusal by the CSR to release information to her on behalf of her mother. Since she already had submitted a power of attorney to the Plan, she was irate that the Plan told her she had to complete an authorized representative form with a signature from her mother, who lived more than an hour away.

The Plan’s resolution letter failed to adequately address all of the issues in this grievance. The letter discussed the Plan’s quality of service review process and enclosed a Designation of Representation form for the daughter to complete. The Plan asserted that it could not release medical or billing information to the daughter until it received this completed form or a power of attorney form. However, it appears that the Plan issued its resolution letter prior to making any effort to locate the power of attorney form that the daughter had already submitted. It should be noted that the Plan’s file did contain a copy of the power of attorney along with the letter from the daughter explaining that she was handling her mother’s financial and health care concerns. Yet, there was no record that the Plan resolved or even addressed the enrollee’s concerns about


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inadequate record keeping. Notably, the Plan’s file did not indicate that it ever acknowledged, considered, investigated, or ultimately resolved the daughter’s fundamental concern that the Plan had not paid her mother’s claims for medical services.

3. The Plan does not perform adequate consideration of enrollee grievances to ensure appropriate resolution.

Case Examples

• The enrollee was admitted as an inpatient for childbirth services. From the documentation in the file, it appeared the enrollee underwent an emergency C-section that required anesthesia services. The provider claim in the file cites diagnosis code 65221 (breech delivery) and CPT codes 01961 AA (anesthesia for C-section) and 99140 (anesthesia add on code for complications by emergency conditions). The Plan’s record of the enrollee’s telephone grievance noted the following:

THERE WAS COMPLICATIONS AT TIME OF SURGERYAND THEY NEEDED AN [ANESTHESIOLOGIST.] [AN ANESTHESIOLOGIST] WAS CHOSEN FOR ME[.] I DIDNT GET TO PICK[,] I WAS NOT IN CONTROL AND I DONT THINK ITS OK THAT IM BEING PUT IN THE MIDDLE[.] ANTH[E]M PLEASE PAY THE REM[A]INDER [OF] 620 DOLLARS[.] THIS WAS NOT IN MY CONTROL AND IT WAS AN [EMERGENCY].

The provider had submitted a $1,600 claim for the anesthesia services. Initially, the Plan processed the claim at the non-participating provider rate, resulting in a Plan payment of $980, leaving the enrollee responsible for a $420 copayment, and a balance of $200, for the amount in excess of reasonable and customary rate, thus totaling the $620.00 bill grieved by the enrollee.

The Plan ultimately agreed to reprocess the claim as a “goodwill gesture” at the participating provider rate as part of the grievance resolution. The Plan issued a revised EOB in which the Plan’s payment rose to $1,490.71, the enrollee’s copayment was reduced to $35.48, and the excess amount was reduced to $73.81. Both the revised EOB and the Plan’s resolution letter advised the enrollee that she was financially responsible for both the copayment and balance of the provider’s bill.

However, documentation in the Plan’s file includes no indication that an investigation was conducted to see whether the anesthesia services were performed on an emergency basis, as the enrollee specifically alluded to in her grievance. This indicates a failure by the Plan to adequately investigate and resolve the enrollee’s grievance. If, as the available facts indicate, these services were emergency based, then the enrollee would not be financially responsible for the amount determined by the Plan to be above the reasonable and customary amount, and would only be held liable for the copayment amount as set forth by


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Rule 1300.71.39(a) and under the Prospect11 decision. If the disputed services were emergency in nature, then the Plan is acting in variance with its Evidence of Coverage (EOC) by improperly processing this claim in a manner that was inconsistent with her contract, and is in violation of Section 1386(b)(1). In addition, the Plan failed to even attempt resolution of her balance billing grievance by notifying the non-contracted anesthesiologist about the balance billing problem.

• This appeal case involved an enrollee who received a bill for $1,175 for an x-ray and other procedures received. The enrollee indicated that she went to the doctor for infertility testing and believed she had authorization for all the services obtained that day. She indicated that the provider did not inform her of any out-of-pocket expenses that were not covered. The Plan’s resolution letter indicated that, based on the information provided, it was determined that the claim had been processed correctly according to her benefit plan. The primary care physician’s (PCP) office had been contacted, and the Plan was informed that the enrollee was advised that only the x-ray had been approved. The Plan encouraged the enrollee to contact her PCP’s office to request a retrospective authorization for all other procedures received.

However, there was no documentation in the file indicating that the Plan conducted adequate consideration of the grievance to determine which services the enrollee was directed by the provider to obtain, or whether or not the enrollee took steps on her own to obtain non-covered services. Although the Plan did take steps to contact her PCP, there is no indication that it followed-up with either the facility or the enrollee for further information. Moreover, the claim sent to the enrollee shows that the Plan failed to pay the previously-authorized x-ray, CPT 74740 ($191). Therefore, this file reflects a violation of the Plan’s obligation to adequately consider the enrollee’s grievance to ensure adequate resolution.

• The enrollee received laboratory testing services totaling $714. The Plan denied coverage for these services asserting that they were related to treatment for infertility, coverage for which is expressly denied under the enrollee’s EOC. The Plan’s phone records for note the following: “MEMBER CLAIM IS BEING REJECTED DUE TO INFERTILITY, MEMBER BELIEVES LAB TESTS THAT WERENT RELATED TO INFERTILITY SHOULD BE PAID ACCORDING TO LAB AND DIAGNOSTIC BE[N]EFITS.” The Plan issued a grievance response letter upholding its previous denial, which, in pertinent part, stated the following:

We are in receipt of an appeal requesting assistance with [a] charge in the amount of $714.00 submitted for lab work related to infertility rendered to you. In your appeal you stated you wanted your claim to be paid according to your lab and diagnostic benefits.

11 See Prospect Medical Group, Inc. v. Northridge Emergency Medical Group (2009) 45 Cal.4th 497.

(The California Supreme Court decided that those who needed emergency services could not be balance billed. Instead, billing disputes must be resolved solely between emergency room doctors and the plan.)


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We have carefully researched your issues and determined the claim was appropriately considered. In order to provide you with a clearer understanding of your benefits and what is not covered, we have enclosed a portion of your Evidence of Coverage (EOC) which explains how infertility treatment is covered.

Therefore, the letter merely maintains that the “claim was appropriately considered” and provided the enrollee with a copy of the section of her EOC related to infertility. The resolution fails to adequately address the enrollee’s assertion that the disputed lab services were not related to treatment of infertility. Furthermore, the Plan’s grievance file contains no documents to demonstrate that the Plan had conducted any research to investigate the possibility that the lab services were not related to infertility.

• During the same month that an enrollee became a member of the Plan, she received inpatient labor and maternity services, including anesthesia services, operating room services, medications, and supplies. The charges for the inpatient services totaled over $28,000.

The following month, the hospital submitted its claim for the inpatient services. According to the Plan, the hospital had submitted the claim under the incorrect identification number. It was not until more than four months later, that the hospital resubmitted the claim correctly under the enrollee’s identification number.

Approximately six months later, the member submitted her grievance to the Plan. At that time, she indicated that the hospital had referred the matter to a collections agency and that the matter would be reported to the credit reporting bureaus. During her phone call to the Plan, the member indicated that she had provided her Anthem identification card to the contracted hospital at the time of her pre-operative appointment and that she had contacted the contracted provider on multiple occasions without ever receiving feedback. The case notes document that the CSR contacted the collections agency to explain the error, and that the collections agency indicated that the enrollee’s account would remain on hold and not be reported on the enrollee’s credit report until the end of the month.

The Plan’s grievance resolution letter to the enrollee contained the following statement: “You will not be responsible for any of the balance of the bill after your plan has paid the Hospital, if they were a plan participating provider at the time of service.” This resolution letter appears confusing because it implies that the issue is not fully resolved until the Plan determines whether the hospital is a participating provider or not. This appears to be form letter language that is misleading because it involves an extraneous variable that has nothing to do with the enrollee’s original complaint. The enrollee expressed her dissatisfaction regarding the fact that the Plan had not paid for the hospital services, and as a result she was now facing a collection action. Although the grievance ultimately was resolved in favor of the enrollee, the Plan’s file contains no documentation to


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reflect that adequate consideration had been performed to uncover why the error occurred.

4. The Plan’s written responses to enrollees do not contain a clear and concise explanation of the resolution, indicating inadequate consideration of the grievance.

The Department’s review uncovered a specific trend whereby some of the Plan’s resolution letters to the enrollees make use of form language that neither applies to the situation at hand, nor provides an accurate explanation of the resolution. Often times, the enrollee’s grievance was a result of the Plan’s administrative error, therefore the resolution response is not only confusing to the member, but misleading as well.

Case Examples

• The enrollee filed a grievance with the Plan because the contracted provider billed him for laboratory services and sent his account to “internal collections” when he did not pay the billed amount of $188. The enrollee requested that he not be billed, as he did not owe anything. The Plan denied the request and the grievance resolution letter offered the following explanation:

[C]ompleted … review of the grievance concerning the claim for September 18, 2012 laboratory services provided by [Provider]. The claim was denied for timely filing … after careful consideration, it’s the [Plan’s] decision to waive the timely filing denial. The claim has been forwarded for processing. You will receive [an] updated explanation of benefits upon completion of the claims processing.

However, according to the documentation in file, the claim appears to have been submitted timely. There appeared to be no factual basis for use of the statement, “waive the timely filing denial.”

The Plan’s Evidence of Benefits (EOB), dated May 2, 2013, contested payment of the claim because the provider who ordered the lab services originally did not provide an NPI number, information the Plan contends was necessary for adjudication of the claim. The Plan’s EOB dated June 5, 2013, denied the claim, noting, “This service was submitted for payment after the claim filing time limit. The member is not responsible for this amount.” The file did not contain a copy of the relevant Evidence of Coverage (EOC) page but set forth a draft letter citing an EOC provision (page not noted) that states, “Claim forms must be received by Blue Cross within 15 months from the date the services or supplies are received.”

Yet the EOB notes the date of service as September 18, 2012 and the Plan received the claim approximately 7 months following the date of service, well within the15-month timeframe as required by the EOC provision. The provider included an NPI number in the claim reprocessed by the Plan on June 5, 2013, eight and one-half months following the date of service, and again within the 15-month timeframe.


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Therefore, there was no basis for the Plan to deny the claim for untimely filing. The Plan’s grievance resolution letter and use of the statement, “after careful consideration, it’s the [Plan’s] decision to waive the timely filing denial” is problematic in that it demonstrates that the Plan did not adequately consider and investigate the grievance.

• The enrollee submitted a complaint directly to the Department on August 13, 2013, indicating that her pharmacy claim in 2012 was submitted to the wrong health plan, and although she had resubmitted the claim to the Plan, she had not yet received reimbursement. It appears that the pharmacy had submitted a claim to BCBS of Illinois for test strips and other supplies, and that after the claim was correctly submitted to the Plan, the Plan paid the claim.

Despite the fact that the enrollee had no part whatsoever in the error that led to her grievance, the Plan’s resolution letter indicated that it had made an administrative decision to make a one-time exception to process her claim. The Plan’s letter stated:

Anthem Blue Cross (Anthem) has completed our review of the grievance …. After a thorough review of your concerns, Anthem has made an administrative decision to do a one-time exception to process the referenced claim for payment. [Emphasis added.]

Nothing in the file indicates that an exception was warranted, as there was no basis for the Plan to exclude coverage. It appears the Plan was obligated to reimburse the member for this claim under the terms and conditions of her health plan contract as the claim that was processed indicated that the pharmacy was a participating provider. The initial submission to an Illinois-based health insurer in no way negates the Plan’s obligation to reimburse the member for this claim once properly submitted. In addition, the “Appeal Decision” category documented in file states, “Overturned – unavoidable.” Although resolution of the case appears to have been appropriate, the underlying reasoning provided to the enrollee in the resolution letter, “an administrative decision to do a one-time exception,” was not.

During an onsite interview with Plan staff, the Vice President of the Grievances and Appeals Department acknowledged that use of the term “administrative decision” or similar language is inappropriate in cases where the Plan remains obligated to cover and pay for the benefit. Despite this confirmation by the Plan, that is what appears to have happened here.

• The enrollee contacted the Plan by telephone and complained she had just received notice “this week” that her policy was cancelled. She indicated that she wanted to keep her insurance and requested to file a grievance with the Plan. The Plan’s investigation revealed that it had inadvertently cancelled the enrollee’s automatic withdrawal payments because it re-keyed the account number incorrectly. Based on this error, the Plan appropriately reinstated the enrollee’s coverage. However, the Plan’s resolution letter failed to acknowledge that the termination of coverage was the result of the Plan’s error. Rather, the


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letter appears to use form language that is used for the general purpose of educating enrollees of potential consequences due to non-payment. The letter indicated that the Plan had made a “ONE TIME ONLY administrative decision” to allow for reinstatement of her policy, and advised the enrollee that her past due premiums must be paid by January 1, 2013 in order for reinstatement to occur. It further instructed:

Should your policy lapse again for non-payment of premiums, you may apply for reinstatement by submitting a new application and any premiums that are owed. Applicants applying for new enrollment are subject to medical underwriting. Enrollment is not guaranteed and will be based on the medical history, as well as the Medical Underwriting Guidelines in effect at the time of application.

However, this language is not applicable to the matter at hand. The Plan’s error in keying in the incorrect account number led to non-receipt of the premium payment and resulting cancellation of the enrollee’s coverage. Therefore, the Plan’s application of “one time only administrative decision” language is wholly inappropriate for this particular enrollee’s grievance. Moreover, in the context of termination of coverage for non-payment, a “one-time exception” is sometimes used to allow for a one-time reinstatement when an enrollee’s coverage is terminated due to non-payment. Therefore, the Plan’s use of this language implies that this particular enrollee has used her one-time exception and that should she fail to pay her premium in the future, she would not be permitted to reinstate again. The Plan’s error appears to result in a punitive action against the enrollee that negatively affects the enrollee’s contractual rights under the EOC. Therefore, the Plan’s resolution letter failed to adequately consider, address, and resolve the enrollee’s grievance.

Section 1368(a)(1) requires the Plan to establish and maintain a grievance system that “ensure[s] adequate consideration of enrollee grievances and rectification when appropriate.” Section 1368(a)(4) and (5), and Rules 1300.68(a)(1) and 1300.68(d)(1)-(3) require the prompt review of enrollee grievances and specify timeframes for written acknowledgment and resolution to the enrollee. Section 1368(a)(5) additionally requires that written responses to grievances include a clear and concise explanation of the reasons for the Plan’s response.

The Department’s review of a random sample of standard grievance and appeal files revealed a pattern of a combination of problematic issues demonstrating non-compliance with various requirements set forth under Section 1368(a) and Rule 1300.68(a) and (d). The Department found the following issues: 1) the Plan did not adequately consider and promptly process without undue delay clear and sometimes repeated expressions of dissatisfaction as grievances, 2) the Plan failed to adequately consider and resolve all enrollee grievances, whether a single issue or multiple issues are raised, 3) the Plan also did not perform a thorough investigation of enrollee grievances to ensure appropriate resolution, and finally, 4) the Plan’s written responses to the enrollee did not contain a clear and concise explanation of the resolution. As a result, the Plan failed in 20% of the grievance files to adequately consider and rectify enrollee grievances.


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These findings show that the Plan failed to fulfill its overall obligation to maintain a grievance system that consistently ensures adequate consideration and rectification of enrollee grievances. Therefore, the Department finds the Plan in violation of these statutory and regulatory requirements.

TABLE 4 Standard Grievances & Appeals

(Full Service)

FILE TYPE NUMBER

OF FILES


Standard Grievances & Appeals

94

Adequate consideration and rectification of enrollee grievances

75 (80%) 19 (20%)

II. Behavioral Health

The Department reviewed a random sample of 54 standard grievance and appeal files to evaluate the Plan’s grievance system in processing behavioral health enrollee complaints. In six of 54 files (11%), the Plan did not adequately consider, investigate, and rectify the enrollee grievances12. The case summaries below illustrate the Department’s file review findings.

• The enrollee’s mother requested that her daughter continue treatment with a Marriage and Family Therapist (MFT) whom she had been seeing since November and had already established a relationship. The enrollee’s mother was under the impression that the MFT was in the process of contracting with the Plan and was unaware that she was currently an out-of-network provider. She indicated that her daughter was suicidal and cuts herself and has had no success working with other therapists. The Plan’s resolution letter appeared to be adequate in that it provided an explanation of the out-of-network denial, the appropriate EOC provision, and a list of in-network MFTs. However, there is no evidence that the Plan adequately considered the immediate nature of the daughter’s condition (suicidal ideation and cutting herself) as the case was not elevated for expedited review. The grievance was received on February 6, 2013 and was resolved on February 28, 2013, thereby undergoing standard grievance processing.

• The enrollee appealed the denial of a request for outpatient professional services indicating that her provider had left the participating practice group, and was no longer able to see her. Therefore, she requested continuity of care with this now out-of-network provider. The Plan’s resolution response indicated that the enrollee does not have out-of-network benefits and referenced the EOC provisions. However, there was no evidence that the Plan fully investigated the

12 See TABLE 5: Standard Grievances and Appeals (Behavioral Health).


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enrollee’s need for continuity of care or whether she had the right to remain with the terminated provider pursuant to the right to “Completion of Covered Services” afforded to all enrollees under Section 1373.96.

• The enrollee appealed the initial denial of inpatient treatment based on lack of medical necessity, alleging that she should not have been sent to collections as it was the provider who failed to submit the request for authorization. The enrollee’s service request ultimately underwent three levels of utilization management review: initial, appeal, and provider dispute resolution. All levels deemed that the service was not medically necessary. Therefore, the Plan upheld the denial based on lack of prior authorization. However, during the Plan’s investigation, it was discovered that the enrollee was sent two Explanation of Benefits (EOBs) with conflicting information. One EOB indicated that she was responsible for payment, while the other indicated that she was not. In addition, the treating provider was a participating provider. Therefore, the enrollee should not have been responsible for payment, even without authorization, unless the enrollee had signed a valid, enforceable waiver to pay for the services. Instead of pending the case while an investigation was conducted to determine whether or not the enrollee had signed a waiver, the case was instead closed with instructions provided to the enrollee to contact the Plan again. This case, therefore, was not adequately investigated and resolved.

• This case involved multiple complaints that were not adequately investigated and resolved. The complainant wrote on behalf of an enrollee who suffers from severe mental illness. The complaint alleges that the enrollee did not receive appropriate medical care at a certain facility and was allegedly subjected to unnecessary tests (CT scan and four chest x-rays). The provider claimed to have seen a shadow in the scan indicating pneumonia and subjected the enrollee to a longer stay than necessary. The complainant indicated that the enrollee should have been transferred to a psychiatric unit immediately. Due to incompetent treatment, the complainant recommended that the Plan limit payment to the hospital. The complainant also insisted that the enrollee not be held liable for the cost-sharing portion of the visit. The Plan’s resolution letter explained that it was the Plan's responsibility to pay all charges for services rendered and that if the complainant feels that the provider has wrongly billed, then the complainant should address the issue with the provider. Otherwise, the enrollee is responsible for copays per the EOC. Further, the resolution letter did not address, investigate, or resolve the complainant's quality of care concerns about overtreatment and incompetence.

Section 1368(a)(1) requires the Plan to establish and maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. Section 1368(a)(5) and Rule 1300.68(d)(3) requires that written responses to grievances include a clear and concise explanation of the reasons for the Plan’s response. The Department’s review of a random sample of standard behavioral health grievance and appeal files revealed eleven percent (11%) of the files did not receive adequate consideration and rectification. The Plan does not maintain a grievance system that consistently ensures adequate consideration and rectification of enrollee grievances, including providing the enrollee with a clear and concise explanation of the


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resolution. Therefore, the Department finds the Plan in violation of these statutory and regulatory requirements.


(Behavioral Health)

FILE TYPE NUMBER

OF FILES



54

Adequate consideration and rectification of enrollee grievances

48 (89%) 6 (11%)


The Plan disputed some of the Department’s findings and requested the Department consider issuing a recommendation in lieu of finding the Plan deficient given the improvements seen in the grievance and appeals processing. Where the Plan agreed with the Department, it used the deficient files as examples in training of Customer Service staff.


The Department reviewed the Plan’s response in detail and declines the Plan’s request to issue a recommendation in lieu of a deficiency. Based upon the Plan’s response, the Department has determined that this deficiency has not been fully corrected. The Department will conduct further file review during a Follow-Up Survey to assess the effectiveness of the Plan’s corrective action.

GRIEVANCES AND APPEALS BEHAVIORAL HEALTH ONLY

Deficiency #5: The Plan does not maintain a grievance system that consistently ensures compliance with all acknowledgment letter requirements.

Statutory/Regulatory Reference(s): Section 1368(a)(4)(A)(ii); Section 1368.02(b); Rule 1300.68(b)(3); and Rule 1300.68(d)(1).

Section 1368(a)(4)(A)(ii) states, “Every plan shall … [p]rovide for a written acknowledgment within five calendar days of the receipt of a grievance … The acknowledgment shall advise the complainant of … [t]he date of receipt.” [Emphasis added.]

Section 1368.02(b) states, “Every health care service plan shall publish the


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department's toll-free telephone number, the department's TDD line for the hearing and speech impaired, the plan's telephone number, and the department's Internet Web site address … on all written notices to enrollees required under the grievance process of the plan, including any written communications to an enrollee that offer the enrollee the opportunity to participate in the grievance process of the plan and on all written responses to grievances. The department's telephone number, the department's TDD line, the plan's telephone number, and the department's Internet Web site address shall be displayed by the plan in each of these documents in 12-point boldface type …”

Rule 1300.68(b)(3) states, “The grievance system shall address the linguistic and cultural needs of its enrollee population as well as the needs of enrollees with disabilities. The system shall ensure all enrollees have access to and can fully participate in the grievance system by providing assistance for those with limited English proficiency or with a visual or other communicative impairment. Such assistance shall include, but is not limited to, translations of grievance procedures, forms, and plan responses to grievances, as well as access to interpreters, telephone relay systems and other devices that aid disabled individuals to communicate.”

Rule 1300.68(d)(1) states, “A grievance system shall provide for a written acknowledgment within five (5) calendar days of receipt, except as noted in subsection (d)(8). The acknowledgment will advise the complainant that the grievance has been received, the date of receipt, and provide the name of the plan representative, telephone number and address of the plan representative who may be contacted about the grievance.” [Emphasis added.]

Assessment: The Department conducted a review of a random sample of 54 standard behavioral health grievance and appeal files to evaluate the Plan’s compliance with sending enrollees written notification in response to grievances filed. In nine of 54 files (17%), the Department identified three areas where acknowledgment letters did not comply with one or more of the following requirements: 1) Timeliness of written acknowledgement, 2) Required language in appropriate format, and 3) Linguistic, cultural, and disability needs of the enrollees addressed13. Case examples identified for each of these areas are included below.

1. Timeliness of Written Acknowledgment

• In two cases, the Plan did not send acknowledgement letters to the enrollee within five calendar days of the receipt of the grievance. Rather, the acknowledgement letters were sent within 14 calendar days and 7 calendar days, respectively.

• The acknowledgment letter in this grievance did not specify the date of receipt. Therefore, the Department was unable to verify that the Plan’s acknowledgement letter was sent to the enrollee within the five calendar days of the receipt of the grievance.

13 See TABLE 6: Grievances and Appeals (Behavioral Health).


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• The acknowledgment letter included a grievance receipt date that differed from the receipt date listed on the resolution letter. With conflicting receipt dates, the Department was unable to verify that the Plan’s acknowledgement letter was sent to the enrollee within the five calendar days of the receipt of the grievance.

2. Required Language in Appropriate Format

• In four grievances, the acknowledgment letters did not include the required language in the appropriate format, including the Department’s telephone number, Department’s TDD line for the hearing and speech impaired, the Plan's telephone number, etc. in 12-point bold face type.

3. Linguistic, Cultural, and Disability Needs of Enrollees Addressed

• In three grievances, the acknowledgment letters did not address the linguistic, cultural, or special needs of the enrollee by including a notice regarding the availability of access to translations, interpreters, or any other forms of assistance.

Section 1368(a)(4)(A)(ii) and Rule 1300.68(d)(1) requires that the Plan provide written acknowledgment within five calendar days of the receipt of a grievance and advise the complainant of the date of receipt of the grievance. Section 1368.02(b) requires the Plan include specific language in an appropriate format. Rule 1300.68(b)(3) requires the Plan’s grievance system to address the linguistic and cultural needs of its enrollee population as well as the needs of enrollees with disabilities. The Department’s review of a random sample of behavioral health grievance and appeal files revealed a 17% non-compliance rate. The Plan does not consistently comply with these acknowledgement letter standards. Therefore, the Department finds the Plan in violation of these statutory and regulatory requirements.


(Behavioral Health)

FILE TYPE NUMBER

OF FILES



54 Compliance with acknowledgment letter requirements

45 (83%) 9 (17%)

Plan’s Compliance Effort: Within 45 days following notice of a deficiency, the Plan is required to file a written statement with the Department signed by an officer of the Plan, describing any actions that have been taken to correct the deficiency.


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In the Plan’s response, it agreed with the Department’s findings. To correct this deficiency, the Plan conducted training and implemented auditing to verify the timeliness and appropriateness of the acknowledgment letters sent.


The Department finds that the Plan has implemented corrective actions to remedy the deficiency identified. However, additional time is necessary to assess the effectiveness of the Plan’s corrective actions. Therefore, the Department has determined that this deficiency has not been fully corrected. The Department will verify implementation of the Plan’s corrective action and conduct file review during a Follow-Up Survey to assess the effectiveness of the Plan’s corrective action.

UTILIZATION MANAGEMENT

Deficiency #6: For decisions to deny, delay, or modify health care service requests by providers based in whole or in part on medical necessity, the Plan does not consistently include in its written response:

• a clear and concise explanation of the reasons for the decision, • a description of the criteria or guidelines used, and • the clinical reasons for the decision.

Statutory/Regulatory Reference(s): Section 1367.01(f) and Section 1367.01(h)(4).

Section 1367.01(f) states, “The criteria or guidelines used by the health care service plan to determine whether to approve, modify, or deny requests by providers prior to, retrospectively, or concurrent with, the provision of health care services to enrollees shall be consistent with clinical principles and processes. These criteria and guidelines shall be developed pursuant to the requirements of Section 1363.5.”

Section 1367.01(h)(4) states, in pertinent part, “Responses regarding decisions to deny, delay, or modify health care services requested by providers … shall be communicated to the enrollee in writing, and to providers initially by telephone or facsimile, except with regard to decisions rendered retrospectively, and then in writing, and shall include a clear and concise explanation of the reasons for the plan’s decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.” [Emphasis added.]

Assessment: To evaluate the Plan’s utilization management processes for modifying or denying requests by providers, the Department selected a random sample of medical necessity denials, delays or modifications. File review identified decision letters that did not consistently include a clear and concise explanation, a description of the criteria or guidelines used, and the clinical reasons for the determination, or some combination thereof, in the following categories: 1) standard denials, 2) delegated denials, 3) standard behavioral health denials, and 4) applied behavioral analysis/therapy (ABA) denials.


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1. Standard Denials – Full Service

The Department reviewed 54 randomly-selected standard denial files. Of the 54 files reviewed, eight (15%) did not contain a clear and concise explanation of the reasons for the Plan’s decision and five (9%) did not provide the clinical reasons for the decisions regarding medical necessity14.

The case summary cited below is an example where, although the Plan’s denial letter included the criteria or guidelines used and the clinical reasons for the denial, the explanation of the decision remained unclear.

Case Example

• This case involved a denial of one of two requested diagnostic services. The denial stated, “We approved your request for initial testing for a condition that can increase your risk of breast cancer (code 81211). Payment for additional testing code (code 81212) is not approved. It can only be approved if initial testing is negative … This is a coding decision only. Your provider can send us a full report after doing the service for review of payment of more codes.” The provider, who is knowledgeable about coding issues, would understand this explanation. However, a layperson may not understand that the Plan’s approval of the second diagnostic procedure is dependent on either a negative or inconclusive test result (the criteria) from the first diagnostic procedure. Therefore, although a description of the criteria was included, and the clinical reason for the decision was provided, the explanation of the denial is not entirely clear and concise to the enrollee.

TABLE 7 Full Service UM Denials

(Standard)

FILE TYPE

NUMBER OF

FILES ELEMENT COMPLIANT DEFICIENT

Standard Denials 54

Clear and concise explanation 46 (85%) 8 (15%)

Clinical reasons for the decision provided 49 (91%) 5 (9%)

2. Delegated Provider Group Denials – Full Service

The Department reviewed 52 randomly-selected delegated provider group denial files. Of the 52 files reviewed, 14 (27%) did not include denial letters that contained a clear and concise explanation for the denial15. Nine cases (17%) did not provide the clinical reasons for the denials.

14 See TABLE 7: Full Service UM Denials (Standard). 15 See TABLE 8: Full Service UM Denials (Delegated Provider Group).


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Case Examples

• The physician requested an MRI of the thoracic spine. The clinical documentation submitted by the physician stated, “Given [patient’s] long history of back pain, but worsening over last year during the same time frame in which this nodule has been getting larger on [patient’s] back will request referral for MRI of T spine to eval.” The Plan’s denial letter stated, "Your request for the MRI of the thoracic spine was denied. Per MCGuidelines 16th edition the criteria for MRI of the thoracic spine are suspected spinal injury, clinical suspicion of cord compression or myelopathy, clinical suspicion of neoplasm, spinal curvature or scoliosis.” Although the denial letter includes a description of the guideline cited, it neither addresses nor refutes the clinical information presented by the requesting physician. Therefore, no clinical reason for the denial is noted and the overall explanation remains unclear.

• The physician requested an MRI of the knee for further evaluation to rule out a meniscus tear. The Plan’s internal notes by the registered nurse/physician indicated the following criteria for the denial and stated, “no history of trauma, edema, swelling, [or] x-ray results.” However, this criteria was not included in the denial letter, which instead stated, “The med[ical] info[rmation] does not doc[ument] that you have an urgent need for an immediate MRI of the knee. An MRI is to assist your phy[scian] in the [diagnosis] and [treatment] of your condition.” The denial letter further directed the enrollee to see a pain management specialist. Therefore, although the Plan’s internal documentation indicated the criteria for the denial, the denial did not, thus, leaving the reason for overall denial unclear.

TABLE 8 Full Service UM Denials

(Delegated Provider Group)

FILE TYPE

NUMBER OF

FILES ELEMENT COMPLIANT DEFICIENT

Delegated Provider Group Denials

52 Clear and concise explanation 38 (73%) 14 (27%)


52 Clinical reasons for the decision provided 43 (83%) 9 (17%)


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3. Standard Denials – Behavioral Health

The Department reviewed 31 randomly-selected standard denial files. Of the 31 files reviewed, 27 (87%) did not include denial letters that contained a clear and concise explanation for the denial16.

Case Examples

• This denial involved an enrollee who self-referred to an inpatient substance abuse unit. The rationale for the denial states:

[T]he information your provider gave us does not show that this is medically necessary. You went to this program to get rehab for your addiction. You had high risk behaviors along with your addiction. You have enough control of yourself to start rehab. You have not caused serious harm to anyone. You have not harmed yourself to such a degree that has caused serious medical problems. You do not require 24 hour supervision. Your rehab can be done in an outpatient program … We based this decision on the HP Guidelines called 2013 Behavioral Health Medical Necessity for Substance Abuse Residential Treatment Rehabilitation.

In the denial cited above, the Plan appears to imply that the ability to control oneself and the absence of serious harm to oneself or others resulted in disqualification of the enrollee for admittance into an inpatient rehabilitation program. This reasoning leads to a number of questions: 1) Does the enrollee need to exhibit lack of self-control in order to be eligible for admittance to an inpatient substance abuse rehabilitation program? If so, does this mean that the enrollee must be referred to the program involuntarily? Many individuals with substance abuse disorders have the insight to realize that they need help; hence, they seek treatment on their own. 2) What does serious harm mean? Does it mean that the enrollee should have had recent suicidal and/or homicidal attempts, or is ideation enough to demonstrate serious harm? This example illustrates how the Plan attempts to imply the criteria for medical necessity by describing the current condition of the enrollee, but fails to explain how the enrollee’s condition failed to meet the criteria.

Notably, “Behavioral Health Medical Necessity for Substance Abuse Residential Treatment Rehabilitation” was referenced, but the specific criteria cited was different from that which was implied in the denial letter. The criteria states:

Must meet 1 or 2 as well as 3 to qualify: 1. Acute psychiatric symptoms that would interfere with a) the covered individual maintaining abstinence and b) recovery outside of a 24 hour structured setting and c) represent a deterioration from their usual status and d) include either self-injurious or risk taking behaviors that poses risk of serious harm to the Covered Individual or others and

16 See TABLE 9: Behavioral Health UM Denials (Standard).


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cannot be managed outside of a 24 hour structured setting. 2. Acute medical symptoms that would likely interfere with the covered individual maintaining abstinence and recovery outside the 24 hour structured setting. 3. Evidence of major functional impairment in at least 2 domains (work/school, ADL, family/interpersonal, physical health).

Therefore, the explanation provided to the enrollee in the denial letter includes reasons that appear misleading and unclear, as they do not directly correlate with the actual Plan criteria.

• This file involved another enrollee who was denied inpatient substance abuse treatment. The rationale for the denial states:

The information your provider gave us does not show that this is medically necessary. You went to this program because your mental health problems were too severe for you to get outpatient rehab. Your mental health condition has improved. The treatment for this can continue outside the program. You no longer need 24 hour supervision. You can continue rehab in an OP program. We based this decision on guidelines… called 2013 BHMN Criteria for SA Res Treatment Rehab.

However, the denial letter does not indicate how the enrollee’s condition has improved to where the criteria for meeting inpatient rehabilitation are no longer met.

TABLE 9 Behavioral Health UM Denials

(Standard)

FILE TYPE

NUMBER OF FILES ELEMENT COMPLIANT DEFICIENT

Standard Denials

31

Clear and concise explanation 4 (13%) 27 (87%)

Standard Denials 31 Clinical reasons for the

decision provided 29 (94%) 2 (6%)

4. Applied Behavioral Analysis/Therapy (ABA) Denials – Behavioral Health

Effective July 1, 2012, Senate Bill 946 mandated coverage of medically necessary Applied Behavioral Analysis/Therapy (ABA) for enrollees diagnosed with autism.

The Department reviewed 53 randomly-selected ABA denial files. Of the 53 files reviewed, 28 (53%) did not include denial letters that contained a clear and concise explanation for the denial and all 53 (100%) did not include a description of the criteria


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or guideline used in making the decision17. The Plan’s Behavioral Health Medical Director included a documented rationale and clinical reason for each medical necessity determination, but no specific criteria or guidelines were referenced. All denial letters simply stated that the services were not medically necessary and generically referred the enrollee/provider to general guidelines for “Psychiatric Outpatient Treatment” posted on the Plan’s website. The lack of description regarding specific criteria and guidelines referenced largely contributed to the lack of clarity in all of the denial letters.

The Behavioral Health Medical Director’s documented rationale for the determinations noted a number of inconsistencies among files whereby there was no clear indication as to why some requests were modified while others were denied. Although each determination was supported by a clinical rationale, the absence of clear criteria or guidelines in place regarding the indication for continued or terminated ABA treatment appears to have contributed to these inconsistencies. The intent of Section 1367.01(h)(4) is to assure the enrollee that medical necessity decisions are made fairly using sound clinical judgment. By citing guidelines not directly related to the requested service, the decision may appear to the enrollee as arbitrary, capricious or based upon pecuniary interests rather than being based on sound clinical judgment.

In an interview with Plan staff, when asked about the lack of autism or ABA treatment-specific criteria or guidelines available, the Behavioral Health Medical Director indicated that the criteria was still in development and that this process has been ongoing for the past year. The criteria still had to undergo committee review and approval. The Plan published guidelines for applied behavioral analysis/therapy subsequent to the on-site survey. However, additional file review of the Plan’s decisions during a Follow-Up Survey is necessary to ensure that the Plan’s decision-making process is consistent in application of the applicable guideline.

Section 1367.01(f) requires that the criteria or guidelines used by the Plan to determine whether to approve, modify, or deny requests by providers shall be consistent with clinical principles and processes. Although evidence exists that the Plan does approve some requested ABA services, it has not demonstrated that denials are based on the appropriate criteria or guidelines that have been adopted. Rather, the Plan cited to general guidelines that appeared to be unrelated to ABA therapy. Therefore, the Department concludes that the Plan’s actions are in violation of this statutory requirement.

TABLE 10 Behavioral Health UM Denials

(Applied Behavioral Analysis Therapy)

FILE TYPE

NUMBER OF FILES ELEMENT COMPLIANT DEFICIENT

ABA Denials 53 Clear and concise

explanation 25 (47%) 28 (53%)

17 See TABLE 10: Behavioral Health UM Denials (ABA).


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ABA Denials 53 Description of the criteria

or guidelines 0 (0%) 46 (100%)

Section 1367.01(h)(4) requires the Plan’s responses to enrollees and providers regarding decisions to deny, delay, or modify health care service requests, based in whole or in part on medical necessity, to include a clear and concise explanation of the reasons for the Plan’s decision, a description of the criteria or guidelines used, and the clinical reasons for the decision. The Department’s review of both full service (standard and delegated provider group) and behavioral health (standard) denials identified letters that did not consistently include a clear and concise explanation and the clinical reason(s) for the denial. Further, the ABA denials were not clear and concise and no description of the criteria or guidelines used was provided. Therefore, Department also finds the Plan in violation of this statutory requirement.


Standard Denials

The Plan conducted a review of the files the Department found deficient and disputed the findings in some of the files. The Plan reported that it developed a Denial Rationale SharePoint site. Rationale templates are used as the framework for denials and include the references to Medical Policy and Clinical Guidelines specific to the decision. A Quick Reference Guide was also created to provide Medical Directors with a process for using the Denial Templates. In addition, Plain Language Thesaurus and Writing Style Guidelines are used by Plan personnel to ensure denials are clear and concise.

The Plan reported that it conducts monthly internal audits of denial rationales to further ensure the Plan is meeting all of the required components. Those audits, with opportunities for improvement, are distributed back to the reviewers.


The Plan reviewed the 14 delegated provider group denial cases that were identified as non-compliant. The Plan agreed with the Department findings and implemented the three following corrective actions:

1. Conducted PMG Webinar Trainings in February 2013 and November 2014 utilizing actual examples from deficient files.

2. In early October 2014, the Plan Medical Director requested Corrective Action Plans from each of the Medical Groups with deficiencies and required the groups to address the following:

• Training and education plan • Education of Physician Reviewers and non-Physician staff • Inter-rater Reliability testing


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• Revisions of the deficient rationale(s) to meet regulatory compliance requirements

All seven medical groups submitted their Corrective Action Plan responses to the Plan as of November 10, 2014. The Plan provided proof that it initiated a Corrective Action Plan with one medical group.

3. The Plan developed a Performance Improvement Escalation Policy, approved by the medical groups. This Policy is applicable for primary medical groups with historical issues with utilization management compliance.

Behavioral Health Denials

The Plan conducted a review of the 31 behavioral health denial cases that the Department identified as non-compliant. The Plan acknowledges the behavioral health denial rationales imply the specific elements of the criteria used in making the decision instead of explicitly stating said elements. The reasons for which the member is not meeting the criteria are also implied instead of being explicitly stated.

The Plan initiated a revision of the behavioral health denial rationales in an effort to be more clear and concise, while providing explicit information regarding the criteria used in making the determination and the way in which the member’s condition does not meet the criteria. The Plan anticipates fully implementing the revisions by March 1, 2015. The Plan submitted sample rationales for the four most frequent denial types:

• Psychiatric Acute Inpatient • Substance Abuse Inpatient Acute Detox • Psychiatric Residential Treatment Center • Substance Abuse Residential Treatment Center

Prior to implementation of the new rationales, the Plan indicated that Behavioral Health Peer Clinical Reviewers will be trained on the usage of the updated rationales during the first quarter of 2015. Following implementation, to ensure ongoing monitoring and compliance, the Plan will conduct a random sample audit of 25% of behavioral health denial rationales. The Plan will continue auditing until a 90% compliance mark for three consecutive months has been reached. Once that goal has been achieved, the Plan will continue to monitor compliance through a random sample audit of 10% of the denial rationales for a period of 12 months.

ABA Denials

The Plan developed new Applied Behavioral Analysis (ABA) clinical guidelines in November 2013 and formally implemented the criteria in California on April 15, 2014. The Plan updated the guidelines in July 2014.

The Plan held two supplemental ABA-specific trainings for the physicians who conduct physician reviews. These trainings focused on Autism Spectrum Disorders (ASD) and included the use of ABA clinical guidelines. These guidelines are publicly viewable on


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the Anthem website: CG-BEH-02 Applied Behavioral Analysis for Autism Spectrum Disorder.

In an effort to ensure denial letters include a clear and concise explanation for the reasons for the denial, the Plan modified the denial rationales to be consistent with its ABA-specific guidelines. Prior to implementation of the new rationales, Peer Clinical Reviewers will be trained on the usage of the updated rationales in the first quarter of 2015. The Plan implemented auditing consistent with its method stated above for behavioral health denials.


From the response provided by the Plan, it is unclear whether the development of the Denial Rational SharePoint, Quick Reference Guide, and additional writing tools are existing processes in place or were newly implemented to correct this deficiency.

The Department finds that the Plan implemented corrective actions in an effort to remedy the deficiency related to the delegated provider group denials and behavioral health and applied behavioral analysis denials found deficient. The behavioral health sample denial rationales appear to improve upon the clarity of the denial letters. However, the ABA sample denial rationales incorporate the medical policy by reference making it difficult to ascertain which subsection of the policy is being applied in some cases. Thus, the basis of the denial appears to be unclear. Furthermore, the ABA sample denials do not describe the criteria being applied nor do they include the name of the policy, making it difficult to locate on the Plan’s website.

Additional time is necessary to assess the effectiveness of the Plan’s corrective actions. File review will be conducted during a Follow-Up Survey to assess compliance with Section 1367.01(h)(4). Therefore, the Department has determined that this deficiency has not been fully corrected.

LANGUAGE ASSISTANCE

Deficiency #7: The Plan does not update its assessment of enrollee language needs and enrollee demographic profile at least once every three years following the initial assessment.

Statutory/Regulatory Reference(s): Rule 1300.67.04(e)(1).

Rule 1300.67.04(e)(1) states, “Within one year of the effective date of this section, every plan shall complete the initial enrollee assessment required by Section 1367.04 of the Act and this section. Every plan shall update its assessment of enrollee language needs and enrollee demographic profile at least once every three years following the initial assessment.” [Emphasis added.]

Assessment: The Plan’s document, “Enterprise Compliance Oversight Plan,” provides a narrative description of the Plan’s Language Assistance Program and satisfies the requirements of Senate Bill 853. That document contains the policy, “Member Assessment,” which describes the Plan’s process in assessing the language assistance

http://www.anthem.com/ca/medicalpolicies/guidelines/gl_pw_c166121.htm

http://www.anthem.com/ca/medicalpolicies/guidelines/gl_pw_c166121.htm


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needs of its enrollees, both initially and on an ongoing basis. It states, “At least every three years, Anthem will update threshold languages based on the needs we have identified.”

Although the Plan completed an initial comprehensive assessment of the language needs of its enrollees in 2009, the Quality of Care Committee minutes (9/13/13) indicate that the Plan is more than one year overdue for reassessment. At the time of the Department’s onsite survey two months later, the update had yet to be completed.

The Plan’s Director II of Customer Care acknowledged that use of the Plan’s original assessment data is not useful, and therefore indicated that customer service representatives routinely inquire about members’ language preferences upon contact and update the database accordingly. The Plan also runs monthly market sector reports of its data to obtain an accurate demographic of the population it serves. He indicated that use of this data along with other resources would better equip the Plan in formulating a streamlined process for updating its enrollee language need assessment in the future.

Rule 1300.67.04(e)(1) requires the Plan to update its assessment of enrollee language needs and enrollee demographic profile at least once every three years. Because the Plan has not conducted an updated assessment since its initial enrollee language needs assessment in 2009, the Department concludes that the Plan’s actions are in violation of this regulatory requirement.


The Plan provided an updated notice of language assistance that it sends annually to all enrollees in order to collect the enrollee’s preferred spoken and written language. However, the disclosure fails to inform how relevant providers will be notified of the preferred spoken and written language of the enrollee as required by Rule 1300.67.04(c)(1)(B). Rather, the notice requires providers to contact the Plan to request each enrollee’s preferred written and spoken language but does not address how the Plan or the enrollee will inform the provider of the preferred spoken or written language. It appears, therefore, that the enrollee, who may be unable to communicate with the provider due to language barriers, may be required to ask the provider to contact the Plan to obtain their preferred spoken language.


In order to develop an enrollee assessment in compliance with Rule 1300.67.04(c)(1), the Plan must survey its enrollees or use a disclosure and develop a demographic profile of its enrollee population to calculate threshold languages using statistically valid methods for population analysis. Plans may use a variety of demographic data in developing the demographic profile, including census data, client utilization data from third parties, data from community agencies and third party enrollment processes including census data. Rule 1300.67.04(e)(1) requires the Plan to update its assessment of enrollee language needs and enrollee demographic profile at least once


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every three years. The Plan failed to provide evidence that it updated its demographic profile and that its disclosure meets all requirements under Rule 1300.67.04(c)(1)(B).

Based upon the corrective actions presented to the Department, the Department has determined that this deficiency has not been corrected.


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SECTION II: SURVEY CONCLUSION

The Department has completed its Routine Survey. The Department will conduct a Follow-Up Review of the Plan and issue a Follow-Up Report.

In addition to deficiencies in Utilization Management and Language Assistance, the Routine Survey discovered widespread systemic failure of the Plan’s Grievance and Appeals Program that negatively impacted likely a large number of enrollees, who were deprived from the full grievance and appeal rights and protections afforded to them under the Knox-Keene Act. The deficiencies cited in the Report will be referred to the Department’s Office of Enforcement for possible disciplinary action.

In the event the Plan would like to append a brief statement to the Final Report as set forth in Section 1380(h)(5), please submit the response via the Department’s Web portal, eFiling application. Click on the Department’s Web Portal, DMHC Web Portal

Once logged in, follow the steps shown below to submit the Plan’s response to the Final Report: Click the “eFiling” link. Click the “Online Forms” link Under Existing Online Forms, click the “Details” link for the DPS Routine Survey

Document Request titled, 2013 Routine Full Service Survey - Document Request.

Submit the response to the Final Report via the “DMHC Communication” tab.

Plan Response to the Final Report

https://wpso.dmhc.ca.gov/secure/login

http://dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/303fsbhpr040315.pdf

Documents

Blue Cross of California Final Report€¦ · Final Report of the Routine Survey March 24, 2015. 933-0303 2 . EXECUTIVE SUMMARY . On August 29, 2013, the California Department of