Use this SOP to recognize, document, and route member complaints and appeals without delaying the member’s right to seek review. A grievance may be written or oral, and staff must provide clear filing options, assistance, and appropriate follow-up.

📚 Resources Needed

✅ Before You Start

  • A grievance is a written or oral complaint expressing dissatisfaction with services provided or the quality of care.

  • A complaint means the member is not happy with CalOptima and/or a provider. This includes concerns about the quality of health care.

  • An appeal means the member asks CalOptima to review a decision that caused the denial of a service, benefit, or claim. Appeals may involve referrals to a specialist, durable medical equipment, payment for services, co-payments, billing issues, reimbursement, or another service the member received or believed should have been received from CalOptima.

  • Never discourage, delay, interfere with, or retaliate against a member for making a complaint or appeal.

  • Protect the member’s privacy. Record and share only the information needed to route, review, and resolve the concern.

🚀 Tips & Tricks

  • Listen without interrupting, acknowledge the concern, and write the member’s description in clear, neutral language.

  • Do not promise a specific outcome or tell the member that a concern does not qualify. CalOptima determines how a complaint or appeal is processed.

  • Ask whether the issue involves a decision to stop, delay, or reduce a previously approved health care service so the continuation-of-service information can be provided immediately.

  • Offer help with forms and filing options, including free interpreter assistance when needed.

📘 Instructions

Step 1: Receive And Identify The Concern

  • Accept complaints whether they are made orally or in writing.

  • Confirm the member’s contact information and document the date the concern was received.

  • Determine whether the concern appears to be a complaint about service or quality of care, or an appeal of a CalOptima decision that denied a service, benefit, or claim.

  • Do not require the member to use a specific format before providing help or routing the concern.

Step 2: Provide The Patient Complaint Form And Assistance

  • Give the member the Besa Health Member Grievance/Complaint Form in paper or electronic form.

  • Offer help completing the complaint or appeal form. CalOptima can provide a no-cost interpreter when the member speaks another language.

  • If the member wants another person to represent them, explain that CalOptima requires written notice authorizing the representative.

Step 3: Explain When To File

  • For anything other than a CalOptima decision denying a service, benefit, or claim, explain that the complaint must be filed within 180 calendar days from the date of the event.

  • If the complaint concerns a decision to stop, delay, or reduce a health care service CalOptima already approved, explain that the member can continue receiving the service while CalOptima reviews the complaint.

  • Promptly contact CalOptima when continuation of an approved service may apply. Do not advise the member to stop care while the complaint is under review.

Step 4: Explain Every CalOptima Filing Option

  • By phone: Call CalOptima Customer Service at 1-714-246-8500 or toll-free at 1-888-587-8088. TDD/TTY users may call 1-800-735-2929.

  • By mail: Write to CalOptima, Grievance and Appeals Resolution Services, 505 City Parkway West, Orange, CA 92868.

  • Online: Go to the CalOptima website, select “Grievance Form,” complete the Online Member Grievance Form, and select “Submit.” The submission is sent to CalOptima’s Grievance and Appeals Resolution Services.

  • In person: Visit CalOptima at 505 City Parkway West, Orange, CA 92868.

Step 5: Route And Log The Grievance

  • Notify the Besa Health Compliance team or the designated office leader promptly after receiving the concern.

  • Enter the grievance in the Patient Grievance Log. Record the date received, patient’s name, person or department to whom the complaint was referred, date of resolution, and resolution or outcome.

  • Store the log and supporting documents in the restricted Compliance location. Do not place unnecessary clinical details in the log.

  • Provide CalOptima with requested information through an approved secure method and within any stated deadline.

Step 6: Explain Ombudsman And Independent Review Options

  • Explain that the State Office of the Ombudsman investigates and helps solve managed-care complaints made by or on behalf of Medi-Cal beneficiaries.

  • The member should first work with CalOptima to resolve the issue.

  • If the member is not satisfied with CalOptima’s decision, or more than 30 days have passed since the complaint was filed, the member may submit an Independent Medical Review or call the State Office of the Ombudsman toll-free at 1-888-452-8609.

  • Additional help is available through the California Department of Managed Health Care website.

Step 7: Follow Up And Close The Log Entry

  • Track the grievance until the responsible party communicates the resolution or outcome.

  • Document the date of resolution and the final resolution or outcome in the Patient Grievance Log.

  • Notify the member of any information Besa Health is responsible for communicating and document the contact.

  • Retain the log entry and related records according to Besa Health’s compliance and record-retention requirements.

🛠 Troubleshooting

The Member Makes An Oral Complaint

Listen, document the member’s statement, offer the complaint form, explain all filing options, and enter the concern in the Patient Grievance Log. An oral complaint is still a grievance.

The Concern May Be An Appeal

Do not make a final determination or delay the member. Help the member contact CalOptima so the denial of a service, benefit, or claim can be reviewed.

A Previously Approved Service May Be Stopped, Delayed, Or Reduced

Contact CalOptima promptly and tell the member that the service may continue while CalOptima reviews the complaint. Do not advise the member to stop the approved service.

The Member Needs Language Or Form Assistance

Offer help completing the form and connect the member with CalOptima for a no-cost interpreter. Document the assistance provided.

The Member Wants A Representative

Tell the member that written notice authorizing the representative must be provided to CalOptima. Help the member contact CalOptima for instructions.

✅ Completion Check

  • The concern was accepted whether oral or written.

  • The member received the Besa Health complaint form and assistance when needed.

  • The difference between a complaint and an appeal was explained without delaying filing.

  • The 180-calendar-day complaint timeframe was explained when applicable.

  • Continuation of an already approved service was addressed when the issue involved stopping, delaying, or reducing that service.

  • All CalOptima phone, mail, website, and in-person filing options were provided.

  • Interpreter and representative options were explained when applicable.

  • The grievance was routed and entered in the Patient Grievance Log.

  • The State Office of the Ombudsman and Independent Medical Review options were explained when applicable.

  • The date of resolution and resolution or outcome were recorded.

References

Patient Form: Besa Health Member Grievance/Complaint Form

CalOptima: CalOptima Website And Online Member Grievance Form • Customer Service 1-714-246-8500 • Toll-Free 1-888-587-8088 • TDD/TTY 1-800-735-2929

Ombudsman And Independent Review: State Office of the Ombudsman 1-888-452-8609 • California Department of Managed Health Care

Source: CalOptima Provider FSR/MRR Binder, page 125 • Revised Jan 2, 2024