COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN

SERVICES ADMINISTRATION – CHAPTER 2

CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100

RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002

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I.PURPOSE: To establish a fair and efficient process for resolving complaints regarding services and supports managed and/or delivered by Community Mental Health for Central Michigan and its contract providers.

II.APPLICATION: The provisions stated herein apply to all consumers of service from the Community Mental Health for Central Michigan provider network.

III.REFERENCES:

  1. MDCH Managed Mental Health Care Grievance and Appeal Technical Requirement (MDCH/PIHP Contract, Attachment P6.3.2.1)
  2. CMHSP Appeal and Grievance Resolution Processes Technical Requirement (MDCH/CMHSP, Attachment C.6.3.2.1)
  3. MDCH Medical Services Administration Bulletin, Beneficiary Eligibility Manual, Beneficiary Hearings Chapter 1, Section 2.
  4. Michigan Department of Community Health Medical Services Administration, Community Mental Health Services Program Manual, Chapter III, page 3.
  5. Balanced Budget Act of 1997 Subpart F – Grievance System
  1. DEFINITIONS:

A. ACTION: / A decision that adversely impacts a consumer’s claim for services due to:
  • Denial or limited authorization of a requested service, including the type or level of service.
  • Reduction, suspension, or termination of a previously authorized service.
  • Denial, in whole or in part, of payment for a service.
  • Failure to make a standard authorization decision and provide notice about the decision within 14 calendar days from the date of receipt of a standard request for service.
  • Failure to make an expedited authorization decision within three (3) working days from the date of receipt of a request for expedited service authorization.
  • Failure to provide services within 14 calendar days of the start date agreed upon during the person-centered planning process and as authorized by CMHCM.
  • Failure of CMHCM to act within 45 calendar days from the date of a request for a standard appeal.
  • Failure of CMHCM to act within three (3) working days from the date of a request for an expedited appeal.
  • Failure of CMHCM to provide disposition and notice to a beneficiaryof a local grievance/complaint within 60 calendar days of the date of the request.

B. ADDITIONAL MENTAL HEALTH
SERVICES / Supports and services available to Medicaid beneficiaries who meet the criteria for specialty services and supports, under the authority of Section 1915(b)(3) of the Social Security Act. Also referred to as "B3" waiver services.
C. ADEQUATE NOTICE: / Provided to a consumer no later than the date of action when there is a denial of services, including hospitalization, or provided at the time the Person-Centered Plan (initially and with any changes) is signed.
D. ADMINISTRATIVE HEARING/FAIR
HEARING: / An impartial review of a decision made by DCH or CMH/contract agency that the beneficiary believes is inappropriate. The impartial review is completed by an Administrative Law Judge of the DCH Administrative Tribunal.
E. ADMINISTRATIVE LAW JUDGE: / A person designated by the MDCH to conduct the hearing in an impartial or unbiased manner.
F. ADVANCE NOTICE: / Written notice advising the consumer of a decision to reduce, suspend or terminate services that are currently being provided. This notice shall be provided, or mailed to, the consumer at least 12 calendar days prior to the proposed date this action is to take effect.
G. APPEAL: / Request for review of an “action” as defined above.
H. AUTHORIZED HEARING
REPRESENTATIVE: / The person who stands in for or represents the beneficiary in the hearing process and has the legal right to do so. This right comes from one of the following sources:
  1. Written authorization, signed by the beneficiary, giving a person authority to act for the beneficiary in the hearing process.
  2. Court appointed guardian or conservator.
  3. Parent with legal custody a minor child.
  4. The beneficiary's spouse, or the deceased beneficiary's widow or widower, ONLY when no one else has the authority to represent the beneficiary.
The Authorized Hearing Representative does not have a right to a hearing, but rather exercises the beneficiary's right. Someone who assists, but does not stand in for or represent the beneficiary in the hearing process, does not need to meet the above criteria.
I. AUTHORIZATION OF SERVICES: / The processing of requests for initial and continuing service delivery.
J.BENEFICIARY: / An individual who has been determined eligible for Medicaid and who is receiving or may qualify to receive Medicaid services through CMHCM.
K. CONSUMER: / Broad, inclusive reference to an individual requesting or receiving mental health services delivered and/or managed by CMHCM, including Medicaid beneficiaries, and all othersreceiving CMHCM services.
L. DENIAL: / Refusal to authorize any CMHCMservices to a new applicant for services or refusal to authorize additional services (more of the same service or new service) to a current consumer.
M. EXPEDITED APPEAL: / The expeditious review of an action, requested by a consumer or the consumer’s provider, when the time necessary for the normal appeal review process could seriously jeopardize the consumer’s life or health or ability to attain, maintain, or regain maximum function. If the consumer requests the expedited review, CMHCM determines if the request is warranted. If the consumer’s provider makes the request, or supports the consumer’s request, CMHCM must grant the request.
N. GRIEVANCE: / Consumer’s expression of dissatisfaction about CMHCM service issues, other than an action. Possible subjects for grievances include, but are not limited to, quality of care or services provided and aspects of interpersonal relationships between a service provider and the consumer.
O. GRIEVANCE PROCESS: / Impartial local level review of a Consumer’s grievance (expression of dissatisfaction) about CMHCM and/or its Provider Network service issues other than an action.
P. GRIEVANCE SYSTEM: / The overall local system of grievance and appeals required for consumers in the managed care context, including access to the fair hearing process for Medicaid beneficiaries.
Q.INDEPENDENT REVIEWER / Person who was not directly involved in either the determination that led to an action or the situation that led to a grievance and who is also qualified to make an independent determination of the dispute.The first choice will be a supervisor from the same county where the grievance or appeal originated, and if none is available, then the program director from the same county, and then a program director in another county.
R. LOCAL APPEALS PROCESS: / Impartial local level review of consumer’s appeal of an action presided over by individuals not involved with decision-making or previous level of review.
S. MEDICAID SERVICES: / Services provided to a beneficiary under the authority of the Medicaid State Plan, Habilitation Services and Support waiver, and/or Section 1915(b)(3) of the Social Security Act.
T. NOTICE OF DISPOSITION: / Written statement of CMHCM’s decision for each local appeal and/or grievance, provided to the consumer.
U. PROVIDER: / One that provides mental health services and/or supports under contract with CMHCM.
V. RECIPIENT RIGHTS COMPLAINT: / Written or verbal statement by a consumer, or anyone acting on behalf of the consumer, alleging a violation of a Michigan Mental Health Code protected right cited in Chapter 7, which is resolved through the process established in Chapter 7A.

V.POLICY:

A.INTRODUCTION:

  1. All consumers have the right to a fair and efficient process for resolving complaints regarding their services and supports managed and/or delivered by Community Mental Health for Central Michigan and its contract providers.
  2. A beneficiary of public mental health specialty services and supports may access several options to pursue the resolution of a grievance or appeal including the State Fair Hearing process, local appeal process and the local grievance process regarding other service complaints. It is important to note that these options may be pursued simultaneously. A provider under contract with acting on behalf of the beneficiary and with the beneficiary’s written consent may file an appeal.

B.The grievance and appeal processes for consumers shall promote the resolution of consumer concerns, as well as support and enhance the overall goal of improving the quality of care. The internal and external grievance and appeal processes shall include:

1.Service Authorization Decisions: When a service authorization is processed (initial request or continuation of service delivery) shall provide the consumer written service authorization decision within specified timeframes and as expeditiously as the consumer’s health condition requires.

2.Notice Requirements: Notice shall be given whenever a Medicaid State Plan, waiver, or alternative service is denied, reduced, suspended or terminated or when a service authorization is not made timely. The notice shall be in writing and will be provided in the language format needed by the individual to understand the content (i.e., the format meets the needs of those with limited English proficiency, and/or limited reading proficiency).

  1. Continuation or Reinstatement of Services: shall continue or reinstate previously authorized services while the local level and/or state level appeal are pending when the consumer requests to have services continued or reinstated or the service were ordered by an authorized provider.
  2. Local Appeals Process: shall comply with Federal regulations to provide a consumer with a local level appeal of an “action”. The local appeal process shall include written notice of disposition for both standard and expedited resolutions within applicable timeframes. Non-Medicaid consumers must be given notice of their right to the MDCH Alternative Dispute Resolution process.
  3. Local Grievance Process: shall provide consumers the right to a local grievance process for issues that are not “actions”. Grievances may be filed at any time by a consumer, guardian, or parent of a minor child or his/her legal representative. If CMHCM fails to respond to a grievance within 60 calendar days, the grievance is considered an “action” and a beneficiary is then entitled to a state fair hearing.
  4. Record Keeping: shall maintain logs regarding appeals and grievances. Data shall be made available to the quality improvement program for review and analysis.

VI.PROCEDURE:

A.SERVICE AUTHORIZATION DECISIONS

  1. Standard Authorization: Notice of the authorization decision must be provided as expeditiously as the consumer’s health condition requires, and no later than 14 calendar days following receipt of a request for service. If the consumer or provider requests an extension or if Community Mental Health for Central Michigan (CMHCM) justifies, to Michigan Department of Community Health (MDCH)upon request, a need for additional information and how the extension is in the consumer’s interest; CMHCM may extend the 14 calendar day time period by up to 14 additional calendar days.

2. Expedited authorization: In cases in which a provider indicates, or CMHCM determines, that following the standard timeframe could seriously jeopardize the consumer’s life or health or ability to attain, maintain or regain maximum function, CMHCM must make an expedited authorization decision and provide notice of the decision as expeditiously as the consumer’s health condition requires, and no later than three (3) working days after receipt of the request for service.

If the consumer requests an extension, or if CMHCM justifies (to MDCH upon request) a need for additional information and how the extension is in the consumer’s best interest; CMHCM may extend the three (3) working day time period by up to 14 calendar days

When a standard or expedited authorization of services decision is extended, CMHCM must give the consumer written notice of the reason for the decision to extend the timeframe, and inform the consumer of the right to file an appeal if he or she disagrees with that decision. CMHCM must issue and carry out its determination as expeditiously as the enrollee's consumer’s health condition requires and no later than the date the extension expires.

B.NOTICE REQUIREMENTS (Appendix A)

  1. Notice of action requirements include:
  2. The requesting provider, in addition to the consumer, must be provided notice of any decision by CMHCM to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested. The notice of action to the provider is not required to be in writing.

b.If the consumer or representative requests a local appeal or a beneficiary requests a state fair hearing not more than 12 calendar days from the date of the notice of action, CMHCM must reinstate with consumer approval the services until disposition of the appeal.

c.If the consumer’s services were reduced, terminated or suspended without an advance notice, CMHCM must reinstate with consumer approval the services to the level before the action

  1. If the utilization review function is not performed within an identified organization, program or unit (access centers, prior authorization unit, or continued stay units), any decision to deny, suspend, reduce, or terminate a service occurring outside of the person-centered planning process still constitutes an action, and requires a written notice of action.

2.Written Notice of Action (both Adequate and Advanced) must contain the following:

  1. What action CMHCM has taken or intends to take.
  2. The reason for the action.
  3. The consumer’s or Provider’s right to file a local level appeal, and instructions for doing so.
  4. The beneficiary’s right to request a State fair hearing, and instructions for doing so.
  5. The circumstances under which expedited resolution can be requested, and instructions for doing so.
  6. An explanation that the consumer may represent himself/herself or use legal counsel, a relative, a friend, or other spokesperson.

3.Advanced Notice must also explain:

  1. The circumstances under which services will be continued pending resolution of an appeal.
  2. How to request that benefits be continued.
  3. The circumstances under which the consumer may be required to pay the cost of these services.

4.Exceptions to the Advanced Notice Rule. CMHCM may mail an adequate notice of action, not later than the date of action to terminate, suspend or reduce previously authorized services, if:

  1. CMHCM receives a clear written statement signed by the consumer or his/her legal representation that:
  2. He/she no longer wishes services.
  3. Gives information that requires termination or reduction of services and indicates that he/she understands that this must be the result of supplying that information.
  1. The beneficiary has been admitted to an institution where he/she is ineligible under Medicaid for further services.
  2. The consumer's whereabouts are unknown and the post office returns CMHCM mail directed to him/her indicating no forwarding address.
  3. CMHCM establishes the fact that the beneficiary has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth.
  4. A change in the level of medical care is prescribed by the consumer's physician.
  5. The date of the action will occur in less than 10 calendar days.
  6. CMHCM has factual information confirming the death of the consumer.

5.Summary of Notice Requirements:

ACTION / TYPE OF NOTICE / TIME FRAME OF NOTICE
Denial of service request / Adequate / At the time of decision
Person-Centered Plan Developed / Adequate / At the time of plan development
Increase in Benefits / Adequate / At time of action
Reduction, suspension, or termination of service currently being received / Advance / 12 days before action
Standard authorization decision that denies or limits services requested / Adequate / Within 14 days of request
Expedited authorization decision that denies or limits services requested / Adequate / Within 3 working days of request
Failure to provide services within 14 calendar days of the start date agreed upon during the person-centered planning process and as authorized by CMHCM / Adequate / At the time of action
Delayed authorization decision for which an extension has not been agreed to / Adequate / Must be provided on the 14th day (or on the 3rd working day for an expedited authorization

C.CONTINUATION OR REINSTATEMENT OF SERVICES

1.CMHCM must continue services previously authorized while the local level appeal and/or State fair hearing are pending if:

  1. The consumer specifically requests to have the services continued, and
  2. The consumer or provider files the appeal timely; and
  3. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment, and
  4. The services were ordered by an authorized provider, and
  5. The original period covered by the original authorization has not expired.

2.When services are continued or reinstated while the appeal is pending, the services must be continued until one of the following occurs:

  1. The consumer withdraws the appeal.
  2. Twelve calendar days pass after the notice of disposition providing the resolution of the appeal against the consumer is mailed, unless the beneficiary, within the 12-day timeframe, has requested a State fair hearing with continuation of services until a State fair hearing decision is reached.
  3. A State fair hearing office issues a hearing decision adverse to the beneficiary.
  4. The time period or service limits of the previously authorized service has been met.

3.If CMHCM, or the State fair hearing administrative law judge reverses a decision to deny authorization of services, and the consumer received the disputed services while the appeal was pending, CMHCM or the State must pay for those services in accordance with State policy and regulations.

4.If CMHCM, or the State fair hearing administrative law judge reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, CMHCM must authorize or provide the disputed services promptly, and as expeditiously as the consumer's health condition requires.

D.LOCAL APPEALS PROCESS (Appendix B, C and D)

1.The appeals process is initiated by an “action’ and consumers or their representatives may also (or instead) file a Local Appeal, under the following conditions:

  1. It has been no more than 45 calendar days from the date of the notice of action.
  2. Oral inquiries seeking to appeal an action will be treated as appeals in order to establish the earliest possible filing date. The oral request for a local appeal is confirmed in writing, unless an expedited resolution has been requested.
  3. When the consumer, or representative, requests a local appeal not more than 12 calendar days from the date of the notice of action, CMHCM shall reinstate the Medicaid services until disposition of the hearing with consumer approval.

2.When a consumer requests a local appeal, designated CMHCM staff will:

  1. Give consumers reasonable assistance to complete forms and take other procedural steps including, but not limited to translation and literacy support. This includes but is not limited to providing interpreter services and toll free numbers that have adequate TTY/TTD and interpreter capability.
  2. Provide written acknowledgement that an appeal has been received.
  3. Enter the appeal into the database to maintain a log of all requests.
  4. Provide for an expedited review process:
  5. Consumers may request an expedited appeal, (or provider making or supporting consumer’s request) indicating that taking the time for a standard resolution could seriously jeopardize the consumer’s life or health, or ability to attain, maintain, or regain maximum function.
  6. If a consumer requests an expedited appeal, a psychiatrist or licensed psychologist will make the determination whether to expedite the appeal or not. If the consumer’s provider makes the request, or supports the consumer’s request, the expedited appeal will be granted.
  7. Select an independent reviewer to review theappeal.
  8. Ensure that the individual(s) who make the decisions on appeal are health care professionals with appropriate clinical expertise when the denial is based on lack of medical necessity or involves other clinical issues..
  9. Provide the consumer with:
  10. Reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing;
  11. Opportunity, before and during the appeals process, to examine the consumer’s case file, including medical records and any other documents or records considered during the appeals process;
  12. Opportunity to include, as parties to the appeal, the consumer and his or her representative or the legal representative of a deceased consumer’s estate;
  13. Information regarding the right to a fair hearing and the process to be used to request the hearing.
  14. Independent reviewer documents the decision and sends to Customer Service Coordinator/designee with a copy to the Deputy Director of Services within the required time frame.
  15. Customer Service Coordinator/designee will log results of appeal into the database.

3.Notice of Disposition Requirements: