Beneficiary Rights

County of Santa Clara Health System

Beneficiary Rights​​

Policy & Procedure Manual (BHSD #11400)​ Click here to open the Policy in .pdf format​

Table of Contents

Reference​

Policy​  

Definitions:

Advance Directive. Written instructions, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by courts of the State), relating to the provision of the healthcare when the individual in incapacitated.

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

Assessment. A service activity designed to evaluate the current status of mental, emotional, or behavioral health. Assessment includes, but is not limited to, one or more of the following: mental status determination, analysis of the clinical history, analysis of relevant cultural issues and history; diagnosis; and the use of mental health testing procedures Beneficiary – A Medi-Cal recipient who is currently receiving services from BHSD or a BHSD contracted provider.

Emergency. A Condition or situation in which an individual has a need for immediate medical attention, or where the potential for such need is perceived by emergency medical personnel or a public safety agency (Health & Safety Code § 1797.07).

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 action is 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.

Procedure

Attachments:

Program Closure – Sample Notification Letter​

Program Closure – Client Tracking Table​

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