Options for Investigation
This investigative form is recommended when a response may require research within the department.
What is an Investigative Review (IR) form?
This is the recipient for a complaint when a member is dissatisfied with the service provided by a receptionist.
Who is the Department Administrator/Manager?
This membership type does not require a review of the member's contract for cost share requests related to care/service.
What is Medicare?
This person cannot be involved in the subject matter of the Grievance, or a subordinate of the person involved in the Grievance.
Who is the investigation recipient?
This department requires an Investigative Review (IR) form to be completed for all concerns.
What is the Medicare Sales and Marketing Department?
This form of investigation is recommended when it facilitates an earlier resolution to an urgent issue.
What is a verbal investigation?
This is the recipient of a complaint when a member is dissatisfied with the care provided by their primary care provider (PCP)?
Who is the Chief of Service/Physician designee?
This department is responsible for general billing questions.
What is the Patient Financial Services (PFS) Department ?
This system is utilized to view patient medical records.
What is HealthConnect?
This is the form that is to be sent when a member has dissatisfaction with a medical provider and does not require follow up.
What is the For Your Information/Action (FYI/A)?
This form of investigation is recommended when a response is not needed.
What is a For Your Information/Acton (FYI/A) form?
This is the recipient who reviews and replies to every issue related to a breach of confidentiality.
Who is the Local Compliance Officer?
This system is utilized to identify the status of a durable medical equipment item.
What is Durable Medical Equipment Order Tracking System (DOTS)?
This recipient reviews investigation questions related to medical necessity requests.
Who is the Chief of Service/Physician Designee?
This form is used when a verbal investigation is completed with the department and the issue still needs to be formally documented.
What is an FYI/A form?
Typically, this investigative form is to be used for Quality of Care issues.
What is the For Your Information/Acton (FYI/A) form?
Use this resource for locating supervisory staff within our medical centers and medical office buildings.
What is the METRS Contact Database?
This online resource explains what Durable Medical Equipment (DME) items are covered as Base items.
What is the California DME Formulary?
This committee reviews medical necessity cases.
What is the Member Issue Resolution Committee (MIRC)?
For this type of request, it is never appropriate to ask the recipient if the request should be granted.
What is a Cost Share Dispute?
It is the foundation for the resolution of the issues and/or requests raised by a member. It is the process whereby all of the relevant facts are compiled, documented and reviewed in order to determine the appropriate resolution.
What is investigation?
This should always be reviewed to determine the appropriate regional forwarding guidelines for Risk issues.
What is the applicable regional Risk Criteria document?
This date is used to determine the appropriate contract to reference when processing post service requests.
What is the date of incident?
This is the process taken when feedback from a recipient is untimely or incomplete.
What is the escalation process?
This type of investigation generally meets the Title 28 NCQA (QOC) requirement.
What is an FYI/A form?