Important update: Regulatory HMO Contract Amendment — HMO Provider Agreement with Anthem Blue Cross (Anthem)

As you may be aware, California Health and Safety Code section 1368.01(b) requires health plan grievance systems to include the following:

• The grievance system shall include a requirement for expedited plan review of grievances for cases 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. When the plan has notice of a case requiring expedited review, the grievance system shall require the plan to immediately inform enrollees and subscribers in writing of their right to notify the department of the grievance. 

In order to allow us to immediately inform members of their right to notify the regulator of the grievance:

• For cases involving an imminent and serious threat to the health of an HMO patient (including but not limited to severe pain and potential loss of life, limb, or major bodily function), participating medical group/full-risk providers must inform Anthem within one hour or attempted best efforts not to exceed two hours if an expedited grievance is received from an HMO member.