Policy - Beneficiary Problem Resolution

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. Behavioral Health Services Department for the County of Santa Clara has a three-tiered resolution process:

  1.  The Provider level, beneficiaries or beneficiary representatives are encouraged to resolve concerns at the program level where services are received.

  2. The BHSD Plan level, a beneficiary may submit a formal grievance and/or appeal to the MCP.

    a. An internal hearing (for uninsured beneficiaries only) is available if beneficiaries are not satisfied with the result of their grievance and appeal.

  3. The State Fair Hearings Division (for Medi-Cal beneficiary only).

    a. Beneficiaries and beneficiary representatives are required to exhaust the BHSD problem resolution process prior to filing for a State Fair Hearing.

  4. The  Internal Fair Hearing (for uninsured beneficiaries only).

    a. Beneficiaries and beneficiary representatives are required to exhaust the BHSD problem resolution process prior to filing for an Internal Fair Hearing.

    ​​BHSD service beneficiaries have rights specific to:

  1. File a grievance/appeal orally or in writing in the language of their choice.

  2. Authorize another person, a representative, to act on their behalf.

  3. To obtain a second opinion (refer to Beneficiary Request for Second Opinion BHSD# 11200.1 and Beneficiary Request for Second Opinion BHSD# 11200.2)

    a) Beneficiaries can delay their grievance/appeal pending the outcome of the second opinion or proceed with both processes at the same time.

  4. At any stage of the problem resolution process, the beneficiary may access:

    a) The DHCS MMCO “Medi-Cal Managed Care Office of Ombudsman” as a neutral advocate to answer questions. These services are available M – F 8 a.m. to 5 p.m. PST at 1-888-452-8609.

    b) For mental health service questions, additional support may also be obtained from one or more beneficiary advocates, including the Mental Health Advocacy Project at 408-294-9730 or 800-248-6427 x420, or Disability Rights California for legal assistance at 800-776-5746.

    c) For substance use services questions, additional support may be obtained at the SUTS Benefits Line (408)-792-5666.

  5. Beneficiaries and their representative (with proper consent), before and during the appeals process, may examine the beneficiary’s clinical record and any other documents and records to be considered during the appeal process. This information will be provided free of charge and sufficiently in advance of the resolution timeframe.

  6. Beneficiaries will be given a reasonable opportunity to present evidence in person as well as in writing.

  7. All grievances, appeals, and expedited appeals will be resolved within the established timeframes and any required notice of an extension is given. See Timeliness Standards Section.

  8.  Will not be subject to discrimination or any other penalty or punitive action for filing a grievance, appeal, or expedited appeal.

  9. Confidentiality will be maintained throughout the beneficiary resolution process.

  10. Beneficiaries may request BHSD assistance in preparing a written appeal.

  11. In the event BHSD does not receive a written, signed Appeal from the beneficiary, BHSD will neither dismiss nor delay resolution of the Appeal.

  12.  Beneficiaries or their representatives have the right to request a State Fair Hearing if BHSD fails to send a resolution notice in response to an Appeal within the required timeframe.

  13. BHSD’s beneficiary problem resolution process will not replace or conflict with the duties of beneficiary’s rights advocates.

BHSD providers contracted to provide services must inform beneficiaries when those services will be reduced, limited, denied, or modified. The mechanism to notify beneficiaries is called a Notice of Adverse Benefit    Determination, NOABD. This policy describes the situations that warrant a NOABD and the process through which a NOABD is issued to ensure accordance with State regulations so that beneficiaries are able to exercise their rights in response to a NOABD

BHSD delegates submission of certain NOABD’s to providers as follows:

   When the Provider:

  1. Is unable to meet timely access standards

  2. Must modify a service requested by a beneficiary.

  3. Must terminate a beneficiary service;

  When the Beneficiary:

  1. Does not meet medical necessity criteria

  2. Requests a service that is not covered

  3. Asks for payment to be approved for a service which was received that BHSD does not cover.

  4. Disputes financial liability such as cost-sharing or co-insurance.

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