Responsible Party /Action Required

Responsible Party

Action Required

ALL PROVIDERS

1. All providers are required to post notices explaining grievance, appeal, and expedited process procedures in locations at all provider and contractor sites. Notices shall be sufficient to ensure that the information is readily available to both beneficiaries and provider staff. The posted notice shall also explain the availability of fair hearings after the exhaustion of an appeal or expedited appeal process.

 

​2. All providers are required to maintain Problem Resolutions Process materials in all threshold languages and make specific forms available in large type font. Materials, forms, and self-addressed envelopes must be readily available for the beneficiary to obtain without having to ask for them. The following materials are those designated to meet these requirements:

 

 a. BHSD Beneficiary Handbook

 

 b. Notice of Privacy Practices

 

c. Provider Lists

 

d. BHSD Grievance, Appeal, and Expedited Appeal, poster, and handouts

 

 ​3. Provide any reasonable assistance to a beneficiary in completing the forms and other procedural steps related to a grievance or appeal. This includes, but is not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability.

 

4. At the beneficiary’s request, providers will identity staff or another individual to be responsible for assisting a beneficiary with the grievance, appeal, or expedited appeal. The identified individual should not be the same person who provides services to the beneficiary.

 

​ 5. Providers will maintain their own Problem Resolution Logs which capture information about all beneficiary problem resolution processes for tracking purposes and used to identify internal or systemic patterns. De-identified Problem Resolution Logs will be sent on a monthly basis to the  BHSD Quality Management for quality improvement activities and state reporting requirements.

 

​6. Staff who make decisions on grievances and appeals must not be involved in any previous level of review or decision-making.

 

​7. Staff who make decisions must have the appropriate clinical expertise in treating the beneficiary’s condition or disease if the decision is based on a denial of medical necessity, of an expedited appeal or the grievance involves clinical issues.

 

8. Will provide any Notice of Adverse Benefit Determinations to BHSD Quality Management, so administrative staff can be alerted to a potential appeal or expedited appeal and for state reporting.

 

​​​Mental Health Division (MHD)
Mental Health Call Center ​

P.O. Box 28504

San Jose, CA 95128

(800) 704-0900

FAX (408) 885.7544

Substance Use Treatment Services (SUTS) 

Quality Improvement and Data Support Division

976 Lenzen Avenue,3rd Floor

San Jose, CA 95126

(408) 792-5666

FAX (408) 947.8707

 

9. Providers will make available the beneficiary’s clinical record, grievance and appeal decision-making materials, and supporting documentation to the designated Quality Improvement Coordinator.

 

10. Maintain NOABDs issued to the beneficiaries and the supporting materials in a centralized notebook for 10 years from the date the NOABD (NOA) was issued unless there are program-specific requirements that demand a longer retention period.

 

​​ 11. Make NOABD and Problem Resolution Notebook available to BHSD and DHCS on request.  

 PROVIDERS THAT HAVE AN INTERNAL PROBLEM
RESOLUTION PROCESS

1. Providers bound by regulations specific to their programs may be required to have their own problem resolution process policies and timeliness. These policies must minimally meet beneficiary rights’ standards and grievance, appeal, and expedited timelines outlined by the state, and these providers are not precluded from adhering to the BHSD Problem Resolution Process.

 

2. Providers that have their own internal grievance procedures are not precluded from the BHSD Problem Resolution Process. Beneficiaries have a right to file a grievance using the BHSD problem resolution process. Providers cannot prevent a beneficiary from filing a grievance with BHSD.​

Assigned BHSD Quality Improvement
   Coordinator or Designated Staff​

​ 1. Guides the beneficiary or authorized representative through the problem resolution process and provides information regarding the status of a beneficiary’s grievance or appeal.

 

2. Ensures that the linguistic and cultural needs of the beneficiary are met. This includes, but is not limited to, being assigned to a staff member who speaks the beneficiary’s native language, use of interpreter services, telephone relay systems, and other devices that aid individuals with disabilities to communicate.

 

3. Enters known beneficiary information in the BHSD Problem Resolution Log within one working day of receipt.

 

4. Sends the beneficiary an acknowledgment letter which is to be postmarked within 5 days of receipt of the grievance.

 

5. Investigates the problem with the beneficiary, representative, and provider in an attempt to reach a resolution.

 

6. Reviews the clinical record, if applicable.

 

7. Coordinates with QA Division Manager, Clinical Standards Coordinator or staff, BHSD Administration, or County Counsel as required to obtain a resolution that is satisfactory to the beneficiary or representative.

 

 8. Documents resolutions within the required timeframes.

 

​ 9. Sends the beneficiary a Notice of Grievance Resolution once the grievance is resolved.

 

10. Advises beneficiary if an extension is required, verbally and in writing, within required timeframes

 

11. Sends a copy of the disposition of the resolution to the provider.

 

12. Completes the Problem Resolution Log with the final disposition, date of resolution, or reason there has not been a final disposition. This log will include Inquiries and Exempt Grievances.

 

13. Stores problem resolution documentation in a confidential secure manner, outside of the beneficiary record, for up to 10 years after the resolution.

 

14. Prepares quarterly reports from the Problem Resolution Log to be reviewed by BHSD Quality Management, Administration, and Behavioral Health Quality Improvement Committee (BHQIC).

 

15. Prepares Problem Resolution Reports for DHCS in accordance with required submission timeframes.​

QUALITY IMPROVEMENT/QUALITY
 MANAGEMENT

1. Reviews grievances/appeals prior to the disposition phase if a resolution is not reached to the satisfaction of the beneficiary. Consults with the BHSD Administration and provides a decision.

 

2. Analyzes the log to identify system gaps and patterns that are problematic and discusses these patterns and potential solutions with BHSD Administration and BHQI Committee.​

​​Internal Fair Hearing Committee
(for Unsponsored Beneficiaries ONLY)

1.   May consist of a Quality Improvement/Quality Management staff or representative, a BHSD Advisory Board staff, and/or a clinic/agency program manager and/or  a licensed clinician that are not involved with the agency in which the beneficiary has grievance  or appeal concern. Under some circumstances, the BHSD Medical Director (or designee) will be  included.

 

2. Meets with the beneficiary and County/Contractor (separately or together) to review the facts of the case, including evidence from both parties, and provides a decision.

 

3. Writes a letter to the beneficiary and County/Contractor regarding the final resolution.

BH​SD Quality Management​​

1. All grievances and appeals shall be reviewed to identify system gaps and patterns that are problematic in order to develop corrective action for system improvement on a quarterly basis.

 

a. Ensures decision-making is done by individuals with authority to require corrective action.

 

b. Reviews grievances and appeals which include but are not limited to:

 

i. Access to Care

 

ii. Quality of Care

 

iii. Denial of Services

 

2. Takes appropriate action to remedy any problems identified.​

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