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95 reasonable amount of time. When determining what a reasonable amount of time is, California considers an expedited review in situations where there is an immediate need for health services. Appeals are forwarded to DHCS within 5 business days of receipt, and are filed within 60 days of the date on the decision notification by vendor or state.

g. California affirms that each applicant or enrollee has the right to represent him or herself or choose a representative, the right to review his or her file and other relevant information and the right to participate fully in the review process. In reviewing the specific requirements of 42 CFR 457.1140(d)(1)-(3) California modified its current appeal language to include an affirmative statement regarding an applicant’s or enrollee’s right to representation and opportunity to review his or her records. California complies with the requirement to allow an applicant or enrollee to participate fully in the review process. Any notification of an appeal able determination includes full notification of appeal rights and instructs the applicant or enrollee that he or she can submit additional information for review.

Guidance: “Health services matters” refers to grievances relating to the provision of health care.

12.2. Health Services Matters- Describe the review process for health services matters that complies with 42 CFR 457.1120.

CA REPSONSE:

a. 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.

DHCS complies with 42 CFR 457.1120(a)(2) using the statewide review system which is required of all health care service plans operating in California, including DHCS and CCHIP participating plans. This system is enforced by the California Department of Managed Care (DMHC). The statewide review system provides an impartial review of any health care service eligible for coverage and payment under a health plan contract. The issues that are handled through this process include: • Accessibility