PIHP
CUSTOMER SERVICES
TRAINING MANUAL
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Mental Health and Substance Abuse Administration
2006
PIHP CUSTOMER SERVICES TRAINING
[Date]
[Place]
Sample Agenda
Part 1: 30 minutes
- Welcome
- Opening remarks
- Housekeeping
- Plan for the day
- Review key terms (in handout)
- Background (Slides 2 & 3)
- Preamble: Welcome to Mental Health
- Functions of Customer Services: The Scope of Your Work
Part 2: 45 minutes
- Standards 1-13
Part 3: 60 minutes
- Standard 14 a – m
Part 4: 60 minutes
- Handbook
Part 5: 30 minutes
- Final Questions and Answers*
- Wrap Up
*For the State training all questions were written on 3x5 cards, and answered at the end of the session. Local trainers could allow questions after each part.
Note: Local trainer may want to have at least one break during the session.
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
PIHP CUSTOMER SERVICES TRAINING MANUAL
INDEX
- Training agenda
- Glossary
- Links to web sites
- Customer services hotline numbers
- Application for Participation 2002 description of Customer Services
- MDCH/PIHP Contract requirement
- Standards VI, VII, and VIII of EQR Protocol
- Michigan’s Mental Health and Substance Abuse Customer Services Standards
- Medicaid Provider Manual Mental Health & Substance Abuse Services Chapter*
- Grid of services
- Person-centered Planning Guideline
- Self-determination Policy
- SAMHSA Definition of Recovery*
- Grievance and Appeal Technical Requirement
- LEP guidance
- Trained Peer Specialist & MDCH contact
- Chart of organization of the Public Mental Health system*
- BBA 42 CFR 438.10: list of requirements
- List of the CMHSP’s customer service representatives
- Handbook template
- List of training participants: PIHP to insert
- Training Power Point *
- Local community resources: PIHP to insert
*Items that are located in separate files.
GLOSSARY
211 Line: Provides 24-7 multi-lingual hotline for Southeastern Michigan linking callers to Health and Human Services agency providers. The line is sponsored by the United Way Services. Note: it is not yet available statewide.
42 CFR: Is a section of the federal code of regulations that list the provisions that are relevant to the enforcement of the Balanced Budget Act
BBA (Balanced Budget Act): The federal fiscal program that defines the limitations and guidelines on programming for mental health issues. Its provisions are located in 42 CFR.
CFR (Code of Federal Regulations): The general and permanent rules and regulations (sometimes called Administrative Law) published in the Federal Register.
CMHSP (Community Mental Health Services Program): The agency or entity responsible for the delivery of mental health services.
DCH: Department of Community Health
DHS (Department of Human Services): The administrative state agency in charge of providing for the administration of state and federal dollars for public and mental health services.
EQRO (External Quality Review Organization): an agency contracted by the Department of Community Health in Lansing to conduct an “audit” on the individual PHIP's and mental health service organizations within Michigan per the guidelines outlined in the BBA.
HSAG (Health Services Advisory Group):The “EQRO” or agency under contract with DCH to complete specific reviews and audit of services within the public mental health system.
MACMHB (Michigan Association of Community Mental Health Boards): The official advocacy body of the Community Mental Health Boards in Michigan.
MCPN (Manager of Comprehensive Provider Network): Agencies that are contracted by PIHP to provide administrative functions and to monitor their contracted service providers used in some PIHP’s (ex. Wayne County).
Medicaid Provider Manual:Manual of information regarding the regulation of Medicaid providers. It is updated at the beginning of each quarter of the fiscal year by the State of Michigan.
Mental Health Code: It is the legal requirements and regulations that govern the provision and administration of mental health services within the state of Michigan.
PIHP (Pre-Paid Inpatient Health Plan): The organization that the Department of Community Health (DCH) contracts with to administer the community mental health services in Michigan.
Public Health Code:It is the legal requirements and regulations that govern the provision and administration of public health services within the state of Michigan.
SA (Substance Abuse) Coordinating Agency: The contracted organizations that are responsible for mandated substance abuse policies and monitoring within a geographically specific area.
State Advocacy Organizations: The private organizations ( NAMI, ARC MP&A etc.) consisting of members who seek to influence, reform, and change the legal and policy requirements of the mental health code in the state of Michigan.
TTY: A specific type of telephone telecommunications device (TTD) used for text communications when one or more of the parties that are hard of hearing, deaf and/or speech difficulty.
Websites: Consumer Advocacy Groups
Bazelon Center for Mental Health Law and Policy:
Depression and Bi-Polar Support Alliance:
Eating Disorders:
Emotions Anonymous:
The Kaiser Family Foundation:
NAMI: National Alliance on Mental Illness:
National Empowerment Center:
OCD Foundation of Michigan:
Schizophrenics Anonymous:
Alcoholics Anonymous:
Detroit Area:
Statewide:
Narcotics Anonymous:
Detroit Area:
Statewide:
ARC Michigan:
Autism Society of Michigan:
Centers for Independent Living:
Epilepsy Foundation of Michigan:
Michigan Protection and Advocacy Service:
United Cerebral Palsy
Metro-Detroit:
Michigan:
United Way
For SE Michigan:
Link to 211 on the homepage
Statewide:
Link to 211 on the homepage
Websites: State and Federal Resources
Department of Health and Human Services / Centers for Medicare and Medicaid:
Medicaid Provider Manual:
Michigan Department of Community Health:
Michigan Mental Health Code:
Michigan Public Health Code:
Michigan Department of Human Services:
MDHS, Links to County Offices:
Michigan Rehabilitation Services:
Links to local offices on the homepage
Michigan Legislative Website (Allows user to look up pending bills and Michigan Compiled Laws by Number):
Michigan Association of Community Mental Health Boards:
Balanced Budget Act:
Type 42CFR438 into the “Quick Search” line.
Use this site for any Federal law, with the number.
National Institute for Mental Health:
Substance Abuse and Mental Health Services Administration:
Limited English Proficiency Guidance in Federal Register:
STATE CUSTOMER SERVICES HOTLINE NUMBERS
Medicaid Customer Services Hotline
1-800-642-3195
Mental Health & Substance Abuse Administration Customer Services Number
1-517-241-5066
MDCH SPECIALTY PRE-PAID HEALTH PLAN 2002 APPLICATION FOR PARTICIPATION
3.6Customer Services
Customer services is an identifiable function that operates to enhance the relationship between the community and applicant, as well as between the individual and the applicant. As such, it must interact with essentially all other aspects of the operations. Customer services include orienting new individuals to the services and benefits available, including how to access services, rights protections processes, helping individuals with problems and inquiries regarding benefits, assisting individuals with, and overseeing complaint and grievance processes, and tracking and reporting patterns of problem areas for the organization. This requires a system that is available to assist at the time the individual has a need for help, and being able to assist on the first contact if at all possible.
General Customer Services Operations
3.6.1 The customer services operation is clearly identified and facilitates:
phone access by the community and service recipients throughout normal business hours (voice mail and answering machines are not considered phone access)
that persons contacting the customer services operation speak with staff who have up-to-date knowledge regarding benefits, the provider network, applicant and network policies/procedures regarding access, service authorization, grievance/appeal procedures, and are skilled in customer relations
a documented process whereby service or process improvement suggestions from individuals are routed in a timely manner to the appropriate part of the operation
integration of individuals and family members into customer services operations including orienting new individuals and their families, creating special project work groups and councils, community awareness outreach initiatives, providing or facilitating arrangements for advocacy when requested, mentoring, developing informational material, and customer satisfaction inquiries.
3.6.2 Customer services staff are knowledgeable regarding referral systems to assist individuals in accessing transportation services necessary for medically-necessary services (including specialty services identified by EPSDT).
3.6.3 A range of methods are used for orienting different populations in the general community to the eligibility criteria and availability of services offered through the applicant network.
3.6.4 Customer services performance standards of effectiveness and efficiency are documented and periodic reports of performance are monitored by the applicant.
3.6.5 The focus of customer services is customer satisfaction and problem avoidance, as reflected in policy and practice.
3.6.6 Customer services is managed in a way that assures timely access to customer services and addresses the need for cultural sensitivity, and reasonable accommodation for persons with physical disabilities, hearing and/or vision impairments, limited-English proficiency, and alternative forms of communication.
3.6.7 The relationship of customer services to required grievance and appeals, and recipient rights processes is clearly defined organizationally and managerially in a way that assures effective coordination of the functions, and avoids conflict of interest or purpose within these operations.
Grievance and Appeal Operations
It is incumbent upon the applicant to have a clearly defined, easily-accessible and responsive system for handling customer appeals and grievances. Staff at all levels and at all service delivery sites of the applicant must have a basic working knowledge of the applicant’s policies and procedures for managing grievances and appeals.
Procedurally, each individual shall be presented with basic information as to what their appeal and grievance rights are and what procedural options exist to resolve service delivery disputes. This includes information about how to access services, helping individuals with problems and inquiries regarding benefits, assisting individuals with complaint and grievance processes, and tracking and reporting patterns of service delivery problems within the organization.
It is important to note that if the applicant is part of an affiliation, the plans must reflect the system that will be in place on 10/1/02 to serve the affiliation’s entire service area.
3.6.8 The applicant employs at least one person skilled in customer relations who is responsible for coordinating all grievances and appeals, and advising individuals of their rights and dispute resolution options.
3.6.9 The grievance and appeal coordinator has a working knowledge of the applicant’s service delivery system and plan benefits.
3.6.10 Posters and/or brochures in alternative formats notifying individuals of their grievance and appeal rights, including mediation, shall prominently include the name and telephone number of the applicant’s appeal and grievance coordinator.
3.6.11 All persons experiencing the need to complain or pursue a grievance or appeal regarding some aspect of their experience with services/treatment which are the responsibility of the applicant, and needing assistance to advance their complaint or grievance, obtain sufficient assistance from customer services staff to succeed in having their concern addressed through the desired process.
Medicaid Managed Specialty Supports and Services Concurrent 1915(b)(c) Waiver Program FY 03 04
6.2Administrative Personnel
The PIHP shall have sufficient administrative staff and organizational components to comply with the responsibilities reflected in this contract. The PIHP shall ensure that all staff has training, education, experience, licensing, or certification appropriate to their position and responsibilities.
The PIHP will provide written notification to MDCH of any changes in the following senior management positions within seven (7) days:
- Administrator (Chief Executive Officer)
- Chief Operating Officer
- Medical Director and Clinical/Program Director(s)
- Chief Financial Officer
- Management Information System Director
- Customer Services Director
- Recipient Rights Officer
6.3Customer Services
6.3.1Customer Services: General
Customer services is an identifiable function that operates to enhance the relationship between the individual and the Prepaid Inpatient Health Plan (PIHP). This includes orienting new individuals to the services and benefits available including how to access them, helping individuals with all problems and questions regarding benefits, handling individual complaints and grievances in an effective and efficient manner, and tracking and reporting patterns of problem areas for the organization. This requires a system that will be available to assist at the time the individual has a need for help, and being able to help on the first contact in most situations. Key aspects of the customer service system are included in Section 3.6 of the Application for Participation.
6.3.2Recipient Rights and Grievance/Appeals
The PIHP shall adhere to the requirements stated in the MDCH Grievance and Appeal Technical Requirement, which is an attachment to this contract (Attachment P 6.3.2.1).
Individuals enrolled in Medicaid must be informed of their right to an administrative hearing if dissatisfaction is expressed at any point during the rendering of state plan services. While PIHPs may attempt to resolve the dispute through their local processes, the local process must not supplant or replace the individual’s right to file a hearing request with MDCH. The PIHP's grievance or complaint process may, and should, occur simultaneously with MDCH’s administrative hearing process, as well as with the recipient rights process. The PIHP shall follow fair hearing guidelines and protocols issued by the MDCH. (Page 31)
EVALUATION ELEMENTS / CRITERIA / SCORING / EXAMPLES OF EVIDENCEStandard VI:Customer Service
- Identifiable Function
Met
Not Met /
- Description of customer services functions
- Member handbooks
- Policies/procedures/protocols for:
- Orienting new individuals/ responding to questions about the services and benefits available to them and how to access them
- Handling complaints and grievances
- Logs/documentation of responses to the above
- Reports of trends, patterns of problem area
- Orienting new individuals to the services and benefits available, including how to access them;
Met
Not Met
- Helping individuals with problems and questions regarding benefits;
Met
Not Met
- Handling individual complaints and grievances in an effective and efficient manner; and
Met
Not Met
- Tracking and reporting patterns of problem areas for the organization.
Met
Not Met
- Access
Not Met /
- Informational materials identifying hours of operation of customer service
- Customer service phone number
- Informed Staff
Substantially Met
Partially Met
Not Met /
- Training materials for customer service staff
- Evidence of customer service staff attendance at training
- PIHP’s process for supervision of customer service staff
- Suggestions from Individuals
Not Met /
- Policies and procedures/ protocols for handling suggestions from individuals
- Standards
Met
Not Met /
- Customer service performance standards
Monitoring of Performance
Met
Not Met /
- Monitoring results
- Cultural Sensitivity and Reasonable Accommodations
Substantially Met
Partially Met
Not Met /
- Customer service policies and procedure
- Cultural competency plan
- Relationship to Grievances and Appeals
Substantially Met
Partially Met
Not Met /
- Customer services policies and procedures
- Functional organizational chart
- Office of Recipient Rights
Not Met /
- Functional organizational chart demonstrating staffing of Office of Recipient Rights
Total Element Score
EVALUATION ELEMENTS / CRITERIA / SCORING / EXAMPLES OF EVIDENCE
Standard VII:Recipient Grievance Process
- General Requirement
Not Met /
- Grievance policies and procedures
- Information to Members
PIHP Contract 6.3.3 / The PIHP must provide enrollees with information about the grievances, procedures, and timeframes that must include:
- The right to file grievances;
- The requirements and timeframes for filing a grievance;
- The availability of assistance in the filing process; and
- The toll-free numbers that the enrollee can use to file a grievance by phone.