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Exhibit N

Subject:

PROVIDER INFORMAL COMPLAINTS AND FORMAL GRI.EVANCES

Objective:

To establish a system for the timely and complete resolution of provider complaints and grievances for the Community Health Plan Medi-Cal

Program.

COMMUNITY

HEALTH PLAN

Policy and Procedure

13.3

Page No: 1 of 4

DEFINITION:

INFORMAL COMPLAINT:

An informal complaint is a complaint which is resolved to the provider's satisfaction within seven (7) calendar days from the receipt

of the grievance.

FORMAL GRIEVANCE

A formal grievance is a complaint which cannot be resolved to the provider's satisfaction within seven (7) calendar days from the receipt

of the grievance.

Formal grievances must

(30)

calendar

days

of

receipt

or

the

date

a

be resolved within thirty complaint becomes a

formal

grievance.

Grievances

include,

but

are

not

limited

to:

provider

issues regarding capitation, contracting, eligibility,

enrollment,

provider

education/information,

marketing, and staff conduct.

CLINICAL GRIEVANCE:

Clinical grievances are informal complaints which suggest a quality of care or clinical issue. Clinical grievances are handled through the

Utilization Management Unit.

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