THE COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN CONSUMER GRIEVANCE SYSTEM

The grievance system includes: A local appeal process for an appeal of an “action” A state level fair hearing process for an appeal of an “action” A local grievance process for expressions of dissatisfaction about any matter other than those that meet the definition of an “action”

ACTION An action is a decision that adversely impacts a Medicaid beneficiaries claim for services due to: Denial or limited authorization of a requested service Reduction, suspension or termination of a previously authorized service

Notice of actions: 1. Adequate Notice of Action 2. Advance Notice of Action

Adequate Notice of Action Written statement advising the beneficiary of a decision to deny or limit authorization of Medicaid services requested. Notice is provided to the Medicaid beneficiary on the same date the action takes effect, or at the time of the signing of the individual plan of service

Adequate notice must contain: A statement of what action is being taken The reasons for the intended action The specific regulations that support the action Explanation of the individual’s right to request a fair hearing and instructions for doing so An explanation that the beneficiary may represent himself/herself or use legal counsel, a relative or friend

Advance Notice of Action Written statement advising the beneficiary of a decision to reduce, suspend or terminate Medicaid services currently provided Notice must be provided/mailed to the Medicaid beneficiary at least 12 calendar days prior to the proposed date the action is to take effect

Advance notice must also contain: The circumstances under which services will be continued pending resolution of the appeal How to request that benefits be continued The circumstances under which the beneficiary may be required to pay the costs of these services

State Fair Hearing Appeal Process Beneficiaries have 90 calendar days from the date of the written notice of action to request a hearing If the beneficiary requests a fair hearing within 12 calendar days from the date of the notice of action, services must be reinstated until disposition of the hearing

State Fair Hearing (cont.) The parties to the state fair hearing include CMHCM, the beneficiary and state level administrative law judge The administrative law judge’s decision and order is the final determination of the department

Local Appeal Process The beneficiary has 45 calendar days from the date of notice of action to request a local appeal If the beneficiary requests a local appeal within 12 calendar days from the date of the notice of action services must be reinstated until disposition of the hearing

Local Appeals (cont.) CMHCM will use the CMHCM Office of Recipient Rights system as the primary local appeal system; however, informal resolution of concerns may first occur with agency supervisors The dispute or grievance can be presented in person, on the telephone or in writing

Local Appeals (cont.) CMHCM must resolve the appeal and provide notice of disposition to the beneficiary within 45 days from the day CMHCM receives the appeal

Expedited Appeals A beneficiary or their provider can request an expedited review when the time for the normal appeal review process could jeopardize the beneficiary's life, health or ability to maintain functioning An expedited hearing is held within 3 workdays after receipt of the hearing request

Grievance Recipient’s expression of dissatisfaction about service issues, other than an action. Possible subjects for grievances include, but are not limited to, quality of care or services provided and aspects of interpersonal relationships between a service provider and the recipient’s.

CMHCM Local Grievance Procedure CMHCM will use the CMHCM Office of Recipient Rights system as the primary local dispute resolution and grievance systems; however, informal resolution of concerns may first occur with agency supervisors.

CMHCM Local Grievance Procedure (cont.) The dispute or grievance can be presented in person, on the telephone or in writing CMHCM will provide the beneficiary written notification of disposition within 60 days from the day the grievance/complaint is received

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