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
Definitions:
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.
Attachments (Templates):
MHD - Attachments
- 1. Beneficiary Grievance & Appeal Form
- 2. Denial of Authorization for Requested Services (NOABD)
- 3. Denial of Payment for a Service Rendered by a Provider (NOABD)
- 4. Delivery System (NOABD)
- 5. Modification of requested Services (NOABD)
- 6. Termination of a Previously Authorized Service (NOABD)
- 7. Delay in Processing Authorization of Services (NOABD)
- 8. Failure to Provide Timely Access to Services (NOABD)
- 9. Dispute of Financial Liability (NOABD)
- 10. Failure to Timely Resolve Grievances and Appeals (NOABD)
- 11. NOABD "Your Rights" Attachment
- 12. Language Assistance Tagline - County
- 12. Language Assistance Tagline - Contractor
- 13. Beneficiary Non-Discrimination Notice
- 14. Letter of Acknowledgement Receipt of Grievance Letter–County
- 15. Grievance Extension Notification Letter- County
- 16. Notice of Grievance Resolution (NGR)
- 17. Notice of Grievance Closure Letter - County
- 18. Letter of Acknowledgment Receipt of Appeal Letter - County
- 19. Notice of Appeal Resolution (NAR)
- 20. Notice of Appeal Resolution -"Your Rights" Attachment
- 21. Extension Notification Letter Appeal County
- 22. Appeal Resolution Letter Upheld
- 23. Appeal resolution Letter Overturned
- 24. Notice of Appeal Closure
- 25. Letter of Expedited Appeal Acknowledgement Receipt
- 26. Extension Notification Letter Expedited Appeal County
- 27. Expedited Appeal Resolution Letter Overturned
- 28. Expedited Appeal Resolution Letter Upheld
- 29. Expedited Appeal Provider Notification
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