Beneficiary Problem Resolution

County of Santa Clara Health System

Beneficiary Problem Resolution

 Policy & Procedure Manual (BHSD #12000)   Click the link to open in .pdf format​

Beneficiaries that receive BHSD services may file a grievance or appeal and have their concerns addressed through a clearly defined problem resolution process if they are not satisfied with their behavioral health services or steps taken by BHSD.  The Policy and Procedure Manual is used for both  MH and SUTS as this is an integrated policy for the ​​Behavioral Health Department Beneficiary Problem Resolution Process. 

Following is a description of the organizational layout of the Manual to assist you in finding the information you need. The Manual consists of a Table of Contents, the Reference,  Policy, Definition, Procedure, Responsible Party /Action Required, Timeline Standards, and the Attachments. 

Table of Contents




Appeal.   A review by BHSD or Contract Agency of an adverse benefit determination.

Beneficiary.  A Medi-Cal recipient who is currently receiving services from BHSD or a BHSD contracted provider.

Grievance.  An expression of dissatisfaction about any matter other than adverse benefit determination. Grievances may include but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the beneficiary’s rights regardless of whether remedial actions requested. Grievance includes a beneficiary’s right to dispute an extension of time proposed by BHSD to make an authorization decision. (42 C.F.R. §   438.400)

Provider.    A person or entity who is licensed, certified, or otherwise recognized or authorized under state law governing the healing arts to  provide  specialty mental health services and who meets the standards for participation in the Medi-Cal program as described in California Code of  Regulations, Title 9, Division 1, Chapters 10 or 11 and in Division 3, Subdivision 1 of Title 22, beginning with Section 50000. The provider includes but is not limited to licensed mental health professionals, clinics, hospital outpatient departments, certified day treatment facilities, certified residential treatment facilities, skilled nursing facilities, psychiatric health facilities, general acute care hospitals, and acute psychiatric hospitals. The MHP is a provider when direct services are provided to beneficiaries by employees of the Mental Health Plan.


Responsible Party/Action Required ​​​

Timeline Standards

Attachments (Templates):

SUTs - Attachments 

 1. Notice of Grievance Resolution (NGR)​ 
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​

2. Denial Notice (NOABD)
English  Spanish  Vietnamese​  Chinese  Tagalog  Farsi​​

3. Payment Denial Notice (NOABD)
English​  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​

5. Modification Notice (NOABD)
 English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​

 6. Termination Notice (NOABD) 
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​

7. Timely Access (NOABD) 
 English​  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​

8. Financial Liability (NOABD)
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​​

9. NOABD “Your Rights” Attachment
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​​​

10. Notice of Appeal Resolution - Determination Upheld (NAR)​​ 
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi

11. NAR “Your Rights” Attachment
English  Spanish​  Vietnamese  Chinese  Tagalog  Farsi​

12. Notice of Appeal Resolution - Determination Overturned (NAR)
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​

13. Beneficiary Non-Discrimination Notice
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​

14. Language Assistance Taglines
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​

15. Authorization Delay Notice (NOABD)
 English​  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​

16. Grievance and Appeal Timely Resolution
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​

Appeal Letter of Resolution Overturned(NAR)​
English​  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​​

Appeal Letter of Resolution Upheld (NAR)​
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​​​​​​

 Appeal Extension Notification template(NOABD)
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi

Grievance Appeal Extension Template (NOBD)
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​

Letter of Acknowledgement Receipt (Grievance & Appeal) - Fillable
English  Spanish  Vietnamese  Chinese  Tagalog  Farsi​

Beneficiary Grievance & Appeal Form - Fillable
English  Spanish  ​Vietnamese  Chinese  Tagalog  Farsi​

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