Utilization Management

The Genex Services grievance process addresses all formal complaints regarding non-clinical and non-determination-related Genex processes or services. The grievance process does not address the clinical decision, but shall instead focus on concerns with the process or people involved in developing the determination. Examples of grievances could be complaints that the UR decision was not done within time frames established by the Labor Code or that the physician who rendered the determination was not licensed.

Genex encourages all stakeholders to resolve individual inquires and problems without the initiation of a formal grievance. Any party who has an inquiry or complaint may contact Genex at 800.844.4235 for verbal resolution. In the event that a complaint may not be settled at the informal level and the party is still dissatisfied, a formal grievance may be filed within one year of occurrence. Grievances must be submitted in writing and shall contain:

  • The party’s name
  • The party’s address
  • The party’s telephone number
  • A summary of the grievance
  • A history of any previous contact made with Genex
  • A description of the relief sought.
  • The party’s signature
  • The date the grievance was signed.

The submitted Grievance Form shall be mailed to P.O. Box 4379, Westlake Village, CA 91359. The Grievance Committee shall acknowledge receipt of the grievance within 5 business days and shall investigate the grievance within 30 days of receipt. Upon conclusion of the investigation, the party shall be notified of the Grievance Committee’s final decision in writing within 30 calendar days.

For complaints regarding clinical decisions/determinations the Genex appeals consideration process, as outlined on all determination letters, allows a formal request for clinical appeals consideration of an adverse determination. The requesting physician may initiate an appeals consideration by contacting Genex at 800.844.4235. An example of an appeal consideration would be a request to reconsider the non-certification of a provider’s request for 24 physical therapy visits. These clinical issues should be addressed by the appeals process and should not be submitted to the grievance process.

Download Grievance Process (PDF)

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