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12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120. Participating plans are required by state law to establish and maintain a grievance system approved by the Department of Managed Health Care (DMHC). The DMHC is responsible for licensing and regulating pre-paid plans (health, dental, and vision) in California. The plan’s grievance process must provide reasonable procedures in accordance with DMHC regulations to ensure adequate consideration of grievances and provide for recertification when appropriate. Subscribers who are not satisfied with the plan’s final determination or who have not received a response to their grievance with 30 calendar days, have the option of appealing to the DMHC. DMHC will review the appeals as a standard review or as an Independent Medical Review (IMR). (The IMR allows subscribers to obtain an impartial review of any health care service eligible for coverage and payment under a health plan contract that has been denied, modified, or delayed by a decision of the plan, or by one of its contracting providers, in whole or in part due to a finding that the services are not medically necessary). The standard review and Independent Medical Review process include a final resolution by DMHC staff or DMHC contractor that is binding on the health plan. The patient protection provision in state law that was established for managed care enrollees in California also apply to HFP and C-CHIP subscribers since they are enrolled in licensed managed care plans. Thus, members are instructed to use their health plan’s grievance process-including the DMHC’s IMR process, if the subscriber has a grievance. When subscribers call MRMIB directly, MRMIB staff serves as an ombudsman assisting subscribers with the grievance process. MRMIB requires all HFP participating plans to report benefits-related grievances once a year. In addition, MRMIB tracks all complaints directly received from subscribers, and any publicly available information on the number and type of benefit grievances filed by subscribers enrolled in a participating plan. Grievance information is used by MRMIB to identify problem areas and to take appropriate steps towards improvements. Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

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