MAX VISION CARE
Written Explanation of Member Grievance Policy and Procedure
DEPARTMENT OF MANAGED HEALTH CARE NOTICE:
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The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 866-557-0518 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. |
Policy
Max Vision Care ("MVC") has established a policy and procedure to address and resolve member grievances in an orderly and timely manner. A "grievance" is a written or oral expression of dissatisfaction regarding MVC and/or an MVC provider, including quality of care concerns. When MVC is unable to distinguish between a grievance and an inquiry, the matter will be considered a grievance. MVC, its employees and its providers will not discriminate against any MVC member because the member filed a grievance.
Responsible
Officer
The Chief Executive Officer, with the assistance of the Optometric Director and Member Relations
Representative, has primary responsibility for the maintenance of the grievance system, including
the review of operations related to any emerging patterns of grievances and in the formulation of
necessary policy changes and procedural improvements.
Addressing
Special Needs of Members
All MVC members will be afforded the opportunity to effectively communicate with MVC
regardless of cultural differences, linguistic limitations or other communicative impairments. MVC
will ensure that all Members have access to and can fully participate in the grievance system by
providing assistance to those with limited English proficiency or with a visual or other
communicative impairment. Such assistance may include, but is not limited to, translations of
grievance procedures, forms, and plan responses to grievances, as well as access to interpreters and
devices that aid disabled individuals to communicate.
Grievance
Resolution Procedure
1. The MVC grievance system shall allow Members to file grievances for at least 180
calendar days following any incident or action that is the subject of the Member's
dissatisfaction.
MVC's providers and staff are proficient in many of the languages commonly spoken by non-
English speaking members. Where necessary, MVC will utilize a translation service to enable
effective communication with its members regarding grievances. Members who are deaf, hard-of-hearing or speech-disabled who use a telecommunication device with a keyboard and visual display
can communicate with MVC regarding grievances by using the California Relay Service. To the
extent applicable, MVC will also ensure that members with visual impairments are able to fully
participate in the grievance process by providing assistance in completing grievance forms and by
communicating orally, in a prompt manner, whenever appropriate.
If a member is unable to participate in the grievance procedure because of his/her age or disability,
the member's representative may pursue a grievance on his/her behalf, and references in this policy
and procedure to the member shall also mean the representative in such cases.
2. All grievances will be initially routed to the Member Relations Representative. The
Member Relations Representative will receive grievances from MVC members either in
person, by telephone, via the MVC Internet website, or in writing. MVC maintains a tollfree
number (866) 557-0518 for submission of grievances that is accessible throughout the
MVC service area. The Member Relations Representative will provide the Member with a
grievance form to complete, which the member may elect to fill out. Grievance forms and
a description of the grievance procedure are available at the MVC administrative office,
through the MVC Internet website, and at contracted provider offices. Grievance forms
shall be provided promptly upon request. Members may obtain assistance in filing a
grievance by contacting the Member Services Representative at (866) 557-0518.
3. Members can submit a grievance online through a hyperlink on the MVC website's home
page clearly identified as "GRIEVANCE FORM." The online grievance form shall be in
HTML format that allows the user to enter required information directly into the form. It
shall allow the subscriber or enrollee to preview the grievance that will be submitted,
including the opportunity to edit the form prior to submittal. It shall include a current
hyperlink to the California Department of Managed Health Care Web site, and the
Department of Managed Health Care Notice on page 1 of this written explanation. All
information submitted through the online grievance process shall be processed through a
secure server.
4. The Member Relations Representative will maintain a written record of each grievance
received.
5. The Member Relations Representative will send a written acknowledgement to the
complainant within five calendar days of receipt of the grievance, unless the grievance
requires an immediate review for an urgent or emergent quality of care issue (see item 8
below), in which case acknowledgement will be handled in an expedited manner. The
acknowledgment letter will advise the member that the grievance has been received and the
date it was received, and provide the name of an MVC employee, phone number and
address of the employee whom the complainant may contact with respect to the grievance.
6. The Member Relations Representative will inform the Optometric Director of the grievance
and forward all relevant documentation to him/her for investigation and resolution.
7. The Optometric Director will review the grievance, obtain additional information if
necessary, and make a finding. The Optometric Director will discuss and review his/her
findings and conclusions with the management or supervisory staff responsible for the
services or operations that are the subject of the grievance.
8. At the direction of the Optometric Director, the Member Relationships Representative will
send a resolution letter to the member within 30 days of receipt of the grievance (except in
the case of an urgent or emergent quality of care issue - see item 8 below - in which case
the resolution will take place in an expedited manner). The resolution letter shall contain a
clear and concise explanation of the reasons for the plan's decision.
9. MVC's responses to grievances involving a determination that a service is not a covered
benefit will specify the provision in the subscriber contract, evidence of coverage or
member handbook that excludes the service. The response will either identify the document
and page where the provision is found, direct the complainant 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 member.
10. MVC provides for an expedited grievance process to respond to grievances involving an
imminent and serious threat to the health of the patient, including but not limited to, severe
pain, potential loss of life, limb, or major bodily function. Upon receiving notice of a
grievance that could meet the above criteria, the Member Relations Representative will
immediately contact the Optometric Director for guidance. If determined to meet the
criteria, the Member Relations Representative and the Optometric Director will do the
following:
b. Provide the complainant and the Department with a written statement on the
disposition or pending status of the urgent grievance within three days of receipt;
and
c. Take into consideration the member's condition when determining the response
time.