Procedure - Beneficiary Problem Resolution

PROCESSES

MANDATED REQUIREMENTS

GRIEVANCE

 1. Timeframes for filing

  1. At any time

 

2. Method of filing

  1. Orally or in writing

 

 3. Who may file

  1. Beneficiary

  2. Authorized representative

  3. Provider on behalf of the beneficiary

 

4. Standard Grievances

  1. Acknowledgement 

    1. In writing  

    2. Postmarked within 5 calendar days of receipt of grievance

  2. Resolution 

    1. Within an established timeframe of 90 calendar days for resolution of grievances except:

      1. Grievances related to disputes of the MCP’s decision to extend the timeframe for making an authorization decision will not exceed 30 calendar days. 

    2. Complete and send the Notice of Grievance Resolution (NGR) template to notify beneficiaries of the results of the grievance resolution. 

      1. NGR will contain a clear and concise  explanation of the decision.

  3. Extensions  

    1. Can be extended an additional 14 calendar days: 
       
      1. Beneficiary requests  
      2. Plan shows a need for additional information and how the delay is in the beneficiary’s interest.  

    2. Provide beneficiary with the applicable NOABD, include status of grievance, estimated date of  resolution, which will not exceed 14 additional calendar days.  

    3. If BHSD extends the timeframe for any grievances that wasn’t requested by the beneficiary, BHSD makes reasonable effort to give the beneficiary prompt oral notice of the delay and give the  beneficiary written notice of   the  extension and the reasons for the extension within 2  calendar days of the decision to extend the timeframe.  

      1. The written notice of extension shall inform the beneficiary of the right to file a grievance if  beneficiary disagrees with the BHSD’s decision

  4. Grievance Process Exemptions  

    1. Grievances received over the telephone in person that are resolved to the beneficiaries  satisfaction by the close of t next business day following receipt are exempt from the written acknowledgement and disposition letters.

    2. Grievances received via mail are not exempt from requirement to send acknowledgement and disposition letters.  

    3. Complaints pertaining to a Notice of Adverse Benefit determination is not considered a grievance and the exemption does not apply

  5. Grievance Logs  

    1. Must maintain a log of all grievances, including the date of receipt of the grievance, the name of the beneficiary, nature of the grievances, the resolutions and the representative’s name who received and resolved the grievances. This includes exempt grievances.  

    2. Must transmit de-identified information that describe issues identified as the result of the grievance, appeal or expedited appeals processes to the BHSD’s administration and/or Quality Improvement Committee for quality improvement purposes.

NOTICE OF ADVERSE BENEFIT DETERMINATION (NOABD)

  1. Written Notice of Adverse Benefit Determination. Requirements must explain:

    1. The adverse benefit determination that has been or will be made.

    2. A clear and concise explanation of the reason(s) for the decision.  

      i.  For determinations based on medical necessity criteria, the notice must include the clinical reasons for the decision and the right to a second opinion.  
      ii.  Will explicitly state why the beneficiary’s condition does not meet specialty mental health services and/or DMC-ODS medical necessity criteria.

    3. A description of the criteria used. This includes medical necessity criteria and any processes, strategies or evidentiary standards used in making such determinations.

    4. The beneficiary’s right to be provided on request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the beneficiary’s adverse benefit determination.   

    5. NOABD must include the name and the direct telephone number or extension of the decisionmaker.

    6. Decisions may be communicated to providers initially by telephone or facsimile and then in writing, except decisions rendered retrospectively. 

  2. Timing of Notice

    1. For termination, suspension or reduction of a previously authorized specialty mental health and/or DMC-ODS service, at least 10 days before the date of the action.

    2. For denial of payment, at the time of any action denying a provider’s claim.  

    3. For decisions resulting in the denial, delay or modification of all or part of the requested specialty mental health and/or DMC-ODS services, within 2 business days of the decision.

  3. Advance Notice Exemptions​

    1. The Plan is exempt from sending an advance notice when:

      ​i.  The provider has factual information confirming the death of a beneficiary.

      ii.  The provider receives a clear written statement signed by the beneficiary that:    
           1. They no longer want services    
           2.  Gives information that requires termination or reduction of services and indicates they understand this must be the result of supplying the information.

      iii. Beneficiary has been admitted to an institution where they are ineligible under the plan for further services.  
       
      iv. Beneficiary whereabouts are unknown and/or post office returns agency mail directed to the beneficiary indicating no forwarding address

      v. Plan establishes that the beneficiary has been accepted for Medicaid services by another jurisdiction, state, territory or commonwealth.

      vi. A change in the level of care is prescribed by the beneficiary’s physician.  
       
      vii. The notice involves an adverse determination made with regard to preadmission screening requirements.

    2. Advance Notice Exemptions date of action will occur in less than 10 days.

WRITTEN NOABD TEMPLATES

  1. Must use DHCS uniform notice templates or the electronic equivalent of these templates generated from the provider electronic health record system.

  2. Notice templates include both the NOABD and “Your Rights” documents.

  3. DENIAL template is used when the MCP denies a request for service. Denials include determinations based on type or level of service, requirements for medical necessity, appropriateness, setting or effectiveness of a covered benefit. For DMC-ODS pilot counties, also use this template for denied residential service requests.

  4. PAYMENT DENIAL Template for is used when the MCP denies, in whole or in part, for any reason, a provider’s request for payment for a service that has already been delivered to a beneficiary.

  5. DELIVERY SYSTEM template is used when the MCP has determined that the beneficiary does not meet the criteria to be eligible for specialty mental health or substance use disorder services through the plan. The beneficiary will be referred to the managed health care plan, or other appropriate system, for mental health, substance use  disorder, or other services.

  6. MODIFICATION template is used when the Plan modifies or limits a provider’s request for a service  including reductions in frequency and/or duration of services and approval of alternative treatments and services.

  7. TERMINATION template is used when the Plan terminates, reduces or suspends a previously authorized  service.

  8. TIMELY ACCESS template is used when there is a delay processing a provider’s and/or beneficiary’s  request for authorization of specialty mental health services or substance use disorder residential services. When the plan extends the timeframe to make an authorization decision, it is a delay in  processing a provider’s and/or beneficiary’s request. This includes extensions granted at the request of the beneficiary or provider and/or those granted when there is a need for additional information from the beneficiary or provider when the extension is in the beneficiary interest.

  9. TIMELY ACCESS template is used when there is a delay in providing the beneficiary with timely services as required by timely access standards applicable to the delayed service.

  10. FINANCIAL LIABILITY template is used when the plan denies a beneficiary’s request to dispute financial liability, including cost-sharing and other beneficiary financial liabilities.

NOABD "YOUR RIGHTS" ATTACHMENTS

  1. Provides beneficiaries with information related to the NOABD:

    1. The beneficiary or provider right to request an internal appeal with the Plan within 60 calendar days from the date on the NOABD.

    2. The beneficiary right to request a State hearing only after filing an appeal with the Plan and receiving a Notice that Adverse Benefit Determination has been upheld.

    3. The beneficiary right to request a State hearing if the Plan fails to send a resolution notice in response to the appeal within the required timeframe.

    4. Procedures for exercising the beneficiary’s rights to request an appeal.

    5. Circumstances under which an expedited review is available and how to request it.

    6. The beneficiaries’ right to have benefits continue pending resolution of the appeal and how to request continuation of benefits.

  2. Utilize the "Your Rights" attachment template or attachments generated from the provider electronic health record system.

  3. Will not alter or change template without prior review and approval from DHCS with the exception of insertion of information specific to beneficiaries’ as required.

​APPEALS

  1. Timeframes for filing

    1. Beneficiaries must file an appeal within 60 calendar days from the date on the NOABD.

  2. Who can file

    1. Beneficiary

    2. Authorized representative

    3. Provider on behalf of the beneficiary with a written authorization from the beneficiary   

  3. Method of filing

    1. Orally

    2. ​In writing

    3. Appeals filed by provider on behalf of beneficiary require written beneficiary consent.

    4. Oral requests for standards appeals shall be followed by a written appeal signed by the beneficiary and confirmation of receipt of appeal.

    5. BHSD and BHSD providers shall assist beneficiary in completing forms and taking other procedural steps to file an appeal including preparing a written appeal, notifying beneficiary of the location of the form on the BHSD website or providing the form to the beneficiary on request.

    6. ​BHSD and providers will advise and assist the beneficiary in requesting continuation of benefits during an appeal of an adverse benefit determination.

    7. In the event that BHSD does not receive a written, signed appeal from the beneficiary, BHSD will not dismiss or delay resolution of the appeal.

  4. Authorized Representatives

    1. With written consent from the beneficiary, a provider or authorized representative may file a  grievance, request an appeal or request a State Hearing on behalf of a beneficiary.

    2. Only the beneficiary can request continuation of benefits.

  5. Standard Resolution of Appeals

    1. Acknowledgement 

      i.   BHSD will provide written acknowledgement of receipt of the appeal. 
      ii.  Acknowledgement letter will include:  
           1.  Date of receipt 
           2.  Name, telephone number and address of the BHSD representative who the beneficiary may contact  about the appeal. 
      iii. Must be postmarked within 5 calendar days of receipt of the appeal.

    2. Standard Resolution Timeframe 
      i.  Must be resolved within 30 days of receipt.

    3. Extension Timeframes 
      i.   BHSD may extend timeframes for appeals by up to 14 calendar days if either of the two conditions  apply: 
      ii.  The beneficiary requests an extension. 
      iii. BHSD demonstrates to the satisfaction of DHCS, on request, that there is a need for additional information and how the delay is in the beneficiary’s best interest. 
            1.  BHSD must provide written notice of the reason for a delay not requested by the beneficiary.    
            2.  BHSD will make reasonable efforts to provide the beneficiary with prompt oral notice of the extension. 
            3.  BHSD will provide written notice of the extension within two calendar days of making the decision to extend the timeframe and notify the beneficiary of the right to file a  grievance if the beneficiary disagrees with the extension. 
           4.   BHSD will resolve the appeal as expeditiously as the beneficiary’s health condition requires and in no event extend the resolution beyond the 14 calendar day extension. 
           5.   In the event that BHSD fails to adhere to the notice and timing requirements, the beneficiary is deemed to have exhausted the BHSD appeal process and may initiate a State hearing.

EXPEDITED RESOLUTION OF APPEALS

  1. General Requirements

    1. BHSD maintains an expedited review process for appeals when BHSD or the provider indicates that taking time for a standard resolution could seriously jeopardize the beneficiary’s mental health or substance use disorder condition, or the beneficiary’s ability to attain, maintain or regain maximum function.

    2. If BHSD denies a request for expedited resolution of an appeal, it will transfer the appeal to the timeframe for standard resolution and comply with: 
      i.   Make reasonable efforts to provide the beneficiary with prompt oral notice of the decision to transfer the appeal to the timeframe for standard resolution. 
      ii.  Provide written notice of the decision to transfer the appeal to the timeframe for standard resolution within two calendar days of making the decision and notify the beneficiary of the right to file a grievance if the beneficiary disagrees with the extension. 
      iii. BHSD will resolve the appeal as expeditiously as the beneficiary’s health condition requires  within the timeframe for standard resolution of the appeal. 

  2. Timeframes for Resolving Expedited Appeals 

    1. BHSD will resolve the appeal within 72 hours from receipt of the appeal.

    2. BHSD will log the time and date of appeal receipt when expedited resolution is requested because  the specific time of receipt drives the timeframe for resolution.

    3. BHSD can extend the timeframe for expedited appeals resolution by 14 calendar days in accordance with federal regulations.

  3. Notice Requirements

    1. In addition to the Notice of Appeals Resolution (NAR), BHSD will make reasonable attempts to provide prompt oral notice to the beneficiary of the resolution.

NOTICE OF APPEAL RESOLUTION (NAR)​

  1. Adverse Benefit Determination Upheld

    1. Used for appeals that are not resolved wholly in favor of the beneficiary.

    2. BHSD will use the DHCS template or electronic equivalent from the BHSD electronic health record system.

    3. BHSD will include the NAR Your Rights attachment as part of the packet sent to the beneficiary.

    4. NARs will include: 
      i.   The results of the resolution and the date it was completed.
      ii.  The reason for the BHSD determination, including criteria, clinical guidelines, or policies used in reaching determination.
      iii. For appeals not resolved wholly in favor of the beneficiary, the right to request a State hearing and how to request it.
      iv. For appeals not resolved wholly in favor of the beneficiary, the right to request and receive benefits while the hearing is pending and how to make that request.
      v.   Notification that the beneficiary may be held liable for the cost of those benefits if the hearing decision upholds the BHSD adverse benefit determination.

  2. NAR “Your Rights” Attachment provides beneficiaries with information pertaining to the NAR:

    1. The beneficiary right to request a State hearing no later than 120 calendar days from the date  of the BHSD written appeal resolution and instructions on how to request a State hearing.

    2. The beneficiary right to request and receive benefits while the State hearing is pending, instructions on how to request continuation of benefits, including the timeframe in which request  shall be made.
      i.  Within ten days from the date the BHSD letter was post-marked or delivered to the beneficiary.

  3. Adverse Benefit Determination Overturned

    1. Used for appeals resolved wholly in favor of the beneficiary.

    2. BHSD will use the DHCS template or electronic equivalent from the BHSD electronic health record system.

    3. BHSD will include the NAR Your Rights attachment as part of the packet sent to the beneficiary.

    4. NARs will include: 
      i.  The results of the resolution and the date it was completed.
      ii. The reason for the BHSD determination, including criteria, clinical guidelines, or policies used in reaching the overturned determination.

    5. BHSD will authorize or provide the disputed services promptly and as expeditiously as the beneficiary’s condition requires on reversal of decision to deny, limit or delay services that were not furnished while the appeal was pending.

    6. BHSD will authorize or provide services no later than 72 hours from the date and time it reverses the determination.

STATE HEARINGS​

  1. Deemed Exhaustion of Appeals Process

    1. Beneficiaries must exhaust the BHSD appeal process prior to requesting a State hearing. 
      i.  After receiving notice that BHSD is upholding an adverse benefit determination. 
      ii. If BHSD fails to adhere to notice and timing requirements.

  2. Timeframes for Filing      

    1. Beneficiaries may request a State hearing within 120 calendar days from the date of the NAR which informs the beneficiary that the Adverse Benefits Decision has been upheld.

    2. BHSD, the beneficiary, his or her authorized representative or the representative of a deceased beneficiary estate are all parties to the State hearing.

  3. Standard Hearing 

    1. ​BHSD will notify beneficiaries that the State must reach its decision on the hearing within 90 calendar days of the date of request for the hearing.

  4. Expedited Hearings

    1. BHSD will notify beneficiaries that the State must reach its decision on the state fair hearing within three working days of the date of the request for the hearing.

  5. Overturned Decisions 

    1. BHSD will authorize or provide the disputed services promptly and as expeditiously as the beneficiary’s health condition requires, but no later than 72 hours from the date it receives notice reversing the BHSD adverse benefits determination.

LANGUAGE ASSISTANCE,

NONDISCRIMINATION

NOTICE AND TAGLINES​​

  1. Translation of Notices

    1. BHSD and providers maintain beneficiary written materials critical to obtaining services in threshold languages and alternative formats. These materials include:
      i.  ​Appeal and grievance notices 
      ii. Denial and termination notices 

  2. ​Nondiscrimination Notice and Language Assistance Taglines

    1. BHSD and providers post nondiscrimination notices and language assistance taglines in waiting areas and with significant communications to beneficiaries

    2. ​BHSD and BHSD providers will not modify or create new DHCS “Nondiscrimination Notice” or  “Language Assistance” taglines without DHCS review and approval prior to use

    3. BHSD and providers post and send nondiscrimination notices and language assistance taglines in  significant communications to beneficiaries

    4. These templates must be sent to beneficiary in conjunction: 
      i.   Grievance Acknowledgement Letter 
      ii.  NOABD  
      iii. ​Appeal Acknowledgement Letter 
      iv. Grievance Resolution Letter 
      v.  Notice of Appeal Resolution​

GRIEVANCE AND APPEAL SYSTEM OVERSIGHT PROCESS​​​

  1. BHSD has established, implemented and maintains a Grievance and Appeal System to ensure receipt, review and resolution of grievances and appeals.

    1. Has and operates within accordance with written policies and procedures regarding its grievance and appeal system

    2. Notifies beneficiaries about its grievance and appeal system: 
      i.   Procedures for filing and resolving grievances and appeals 
      ii.  A toll-free number or local telephone number 
      iii. Address for mailing grievances and appeals

    3. Maintains grievance appeal and expedited appeal forms in areas that beneficiaries can access without making verbal or written request at all sites.

    4. Posts the description for filing grievances and appeals in readily available locations at each plan provider site and on the BHSD website.

    5. Ensures beneficiary or authorized representative assistance in filing grievances and appeals at each location where grievances and appeals are submitted.

    6. Grievance and appeals forms are provided promptly on request.

  2. Employs staff who have the appropriate clinical expertise that can ensure adequate and appropriate consideration of grievances and appeals, as well as rectification when appropriate.

    1. Ensures that multiple issues are addressed and resolved.

  3. Maintains a written record for each grievance and appeal received by BHSD. The log will contain:

    1. The date and time of receipt of the grievance or appeal.

    2. The name of the beneficiary filing the grievance or appeal.

    3. The name of the representative recording the grievance or appeal.

    4. A description of the complaint or problem.

    5. A description of the action taken by BHSD or the provider to investigate and resolve the grievance or appeal.

    6. The proposed resolution by BHSD or the provider.

    7. The name of the provider and staff responsible for resolving the grievance or appeal.

    8. The date of notification to the beneficiary of the resolution.

  4. De-identified written record of grievances and appeals are submitted quarterly to the Behavioral Health Quality Improvement Committee (BHQIC) for systemic aggregation and analysis for quality improvement.

    1. Appropriate action will be taken to remedy any problems identified.

  5. Grievance and appeals reviewed include but are not limited to:

    1. ​Access to Care

    2. Quality of Care

    3. Denial of Services 

  6. BHSD ensures decision-making is done by individuals with authority to require corrective action.​ 

  7. BHSD addresses the linguistic and cultural needs of its beneficiary population, including those needs of beneficiaries with disabilities such as visual or communicative impartments. BHSD assistance includes but is not limited to:

    1. Translation of grievance and appeal procedures, forms and plan responses to grievances and appeals.

    2. Access to interpreters, telephone relay systems and other devices that aid individuals with disabilities to communicate.

  8. BHSD ensures that there is no discrimination agains​t a beneficiary because the beneficiary filed a grievance or an appeal.​

  9. BHSD ensures that the person making the final decision for the proposed resolution of a grievance or appeal has not participated in any prior decisions related to the grievance or appeal, and was not a subordinate of any individual who was involved in a previous level of review or decision-making. Additionally, the decision-maker will be a health care professional with clinical expertise in treating a beneficiaries condition or disease if any of the following apply:

    1. An appeal of an Adverse Benefit Determination that is based on lack of medical necessity

    2. A grievance regarding denial of an expedited resolution of an appeal.

    3. Any grievance involving clinical issues.

  10. BHSD ensures that individuals making decisions on clinical appeals take into account all comments, documents, records, and other information submitted by the beneficiary or the beneficiary’s authorized representative, regardless of whether such information was submitted or considered in the initial Notice of Adverse Benefit Determination.

  11. BHSD provides the beneficiary or beneficiary’s authorized representative the opportunity to review the beneficiary case file, including medical records, other documents or records, and any new or additional evidence considered, relied upon or generated by BHSD in connection with any standard or  expedited appeal of an Adverse Benefit Determination. This information is provided free of charge and sufficiently in advance of the resolution timeframe.

  12. BHSD provides the beneficiary or authorized representative a reasonable opportunity, in person  or in writing, to present evidence and testimony. BHSD notifies the beneficiary or authorized  representative of the limited time available for this sufficiently enough in advance of resolution  timeframe for appeals and in the case of expedited resolution.

  13. BHSD ensures that decision makers on grievances and appeals of adverse benefit determinations  take into account all comments, documents, records, and other information submitted by the  beneficiary or beneficiary’s representative, without regard to whether such information was  submitted or considered in the initial adverse benefit determination.

  14. BHSD is responsible for ensuring their delegates comply with applicable state and federal laws  and regulations, contract requirements and other DHCS guidance. These requirements are communicated to all BHSD providers.​

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