Presentation on theme: "Member “Grievance” and “Appeals” Process Venture Behavioral Health Member Services Department."— Presentation transcript:
Member “Grievance” and “Appeals” Process Venture Behavioral Health Member Services Department
Member “Grievance “ and “Appeals” Process Members have the ability to fully participate in their services, including using the Grievance and Appeals systems, when not satisfied The Medicaid system, which traditionally has had no limits on services, now has limits imposed by utilization management under managed care- therefore, members have rights to contest such limits that occur outside of their participation The system is set up to accommodate the member. Therefore, each member has several mechanisms to use (depending upon whether they are filing a “Grievance” or they are appealing an “Action”)
What is a “Grievance”? Grievance This is a formal way for our members to tell us they are unhappy with service issues, that are NOT about an “action”. This would include how they were treated by staff, what they thought of the agency’s office, if they are having problems with their current caseworker, therapist or doctor, as well as several other scenarios where they are unhappy with something the agency does.
What is an “Action” Action is a decision that negatively impacts a Medicaid member’s claim for services due to: Denial or limited authorization of a requested service. Reduction, suspension, or termination of a previously authorized service Denial, in whole or in part, of payment for a service Failure to make a standard authorization decision and provide notice about the decision within 14 calendar days from the receipt of a standard request for a service Failure to make an expedited authorization decision within 3 working days form the date of receipt request for expedited service authorization Failure to provide services within 14 calendar days of the start date agreed upon during the person- centered planning and as authorized
What is an “Action”Continued Failure to act within 45 calendar days from the date of a request for a standard appeal Failure to act within 3 working days from the date of a request for an expedited appeal Failure to provide disposition and notice of a local grievance/complaint within 60 calendar days of the date of the request.
So What Can A Member Do If They Are Unhappy With Services? They can let their case manager, therapist, or program supervisor know. OR They can file the Grievance or appeal the “Action” directly with the Member Services Representative If the Grievance or Appeal is filed with someone other than the Member Services Representative, all supporting information must be forwarded to that Member Service Representative to be logged in the Grievance and Appeals database.
Who can File a Grievance or Appeal? The Consumer/Member Guardian Parent of a minor child Legal Representative Providers (Local Level Appeals) Providers may only file a Grievance, or request a State Fair Hearing, if the state permits the provider to act as the enrollee's authorized representative
What type of information needs to be documented For A Grievance? Case number Medicaid ID number Who the complainant is (member, legal representative, or parent of a minor member) Date the Grievance was received Date that the Grievance was acknowledged in writing Date it was resolved Date the member was notified in writing of the resolution Type of Grievance Comments/description of what had occurred ***IMPORTANT*** IF THE GRIEVANCE WAS NOT RESOLVED IN 60 CALENDAR DAYS, WITH WRITTEN NOTIFICATION TO THE MEMBER, THIS IS NOW AN “ACTION” AND THEY HAVE THE RIGHT TO APPEAL
What Needs To Be Documented For An Appeal? Case number Medicaid ID number Who is appealing the action? ( Member, Legal Representative, Parent of the Minor Member, or Provider) Date the request for an Appeal was received Date the request for an Appeal was acknowledged in writing Date Appeal was resolved Date member was notified in writing of the resolution Type of Action Staff responsible to resolve Resolution at the local level (Did corrective action take place? Did it go to a State Fair Hearing? Was the request withdrawn? Was it resolved- in member’s favor or not in members favor?)
What needs To Be Documented for an Appeal Continued… Were they satisfied with the resolution Was the appeal regarding a mental health code protected right, and were they informed of the right to file a Recipient Rights Complaint Were they informed of their right to appeal to Venture Was it resolved internally or at a State Fair Hearing What was the outcome if there was a State Fair Hearing Was there a request for continuation of benefits during the appeal, and was it approved Comments/description of what had occurred
What Are The Options For A Member Appealing An “Action”? Denial of Hospitalization or Initial Access to CMHSP Service Program Second Opinion Local Level Appeal State Fair Hearing Suspension, Termination, Reduction, or Unreasonable Delay of a Medicaid Covered Service Local Level Appeal State Fair Hearing Members have the right to access these appeal processes one at a time, or all at the same time, as long as they are requested within the timelines specified by the state
Timelines and Process For Request and Resolution Second Opinions Whenever an initial service or a hospitalization is denied, a consumer must be informed of their right to a Second Opinion Second Opinion requests go to the CEO of the agency, who then must arrange for an evaluation by a physician or licensed psychologist within 3 days (excluding Sundays and legal holidays) unless it is an emergency Second Opinions in situations assessed to be of an emergent nature, will be conducted within 24 hours If the request for a second opinion is denied- this is a violation of their Mental Health Code protected rights- and they should be assisted in filing a Recipient Rights Complaint
Timelines and Process Continued….. Local Level Appeal Must be requested within 45 days from the date of the “Notice of Action” Written notice of the Disposition must be given within 45 days the request for appeal was made If the consumer is not satisfied with the disposition, they are able to appeal that decision with Venture.
Medicaid Fair Hearing Process State Fair Hearing Consumers are entitled to State Fair Hearing by an Administrative law judge, for both Medicaid “State Plan Services” and “Alternative Services” The request must be made within 90 calendar days from the date of the “Notice of Action” If the decision is not in the consumers favor, and they requested and continued to receive services, they may be asked to reimburse for the cost of the services
Reinstatement or Continuation of Medicaid Services Medicaid services that were previously authorized, must continue while the local level appeal and/or the State Fair Hearing are pending if: The member specifically requests to have the services continued; and The request is made within 12 calendar days; and The appeal involves the termination, suspension, or reduction, of the previously authorized course of treatment; and The services were ordered by an authorized provider; and The original period covered by the original authorization has not expired
Services must continue until…. The member withdraws the appeal; or 12 days after mailing the notice of disposition following a Local Level Appeal (unless within that time they request a State Fair Hearing); or The State Fair Hearing office issues a hearing decision adverse to the member; or The time period or service limits of the previously authorized service has been met
What Situations Require A Specific Notice To The Right Of A Medicaid Fair Hearing Or Other Grievance Process? When a consumer is expressing dissatisfaction with the CMHSP they should be informed that they can file a written grievance with the agency If the Grievance was not resolved within 60 days, the consumer must be informed that they now have the right to a local level appeal and /or a State Fair Hearing When denied an initial service and/or hospitalization, all consumers are provided a right to a Second Opinion and local level appeal process, but only Medicaid consumers also have the right to a State Fair Hearing Whenever a new treatment plan is done, all consumers receive an “IPOS notice” Notices given to indicate a change in services in which the consumer was not part of must be mailed within 12 days before the action is to take effect
How Does the Consumer Learn of These Processes? They are given the information at the time of the screening/intake They are given this information at each annual plan They are given this information at the time they let know someone know they are dissatisfied They are given this information upon request They are given this information each time a “Notice of an Action” is going to occur This Information is located in the Venture Member Handbook given to each consumer with Medicaid
How Are most Grievances and Appeals Avoided? By involving the consumer in decisions about their treatment By negotiating alternatives when services requested do not match the consumer’s needs By asking the consumer frequently (at least at periodic review) whether they are satisfied with services By reviewing the person centered plan to assure that the consumer believes that it continues to be appropriate and is still meeting their expectations.
Your Member Services Representatives Barry County CMHA Deb Brice Summit Pointe Nichole Boyd Pines Behavioral Health Mitch Rice Riverwood Center Pat Friend- Fair Hearing Officer Melissa Ludwig- Customer Service Van Buren County CMH Liz Courtney Venture Behavioral Health Natalie Tenney