Appeals and Grievances Understanding Actions, Notices and Second Opinions Pines Behavioral Health

The Grievance System Managed care has put limits on Medicaid - an insurance that is an entitlement and originally was designed not to have limits. Managed care has put limits on Medicaid - an insurance that is an entitlement and originally was designed not to have limits. As a result, grievance systems have been created to protect the consumer, for example: As a result, grievance systems have been created to protect the consumer, for example: Notices of Actions Regarding their ServicesNotices of Actions Regarding their Services The Right to Request Medicaid Fair HearingsThe Right to Request Medicaid Fair Hearings Customer Service DepartmentsCustomer Service Departments Recipient Rights OfficersRecipient Rights Officers Second Opinion ProcessesSecond Opinion Processes

Medicaid vs. Non-Medicaid The Medicaid beneficiary is covered by federal laws protecting them from adverse managed care decisions The Medicaid beneficiary is covered by federal laws protecting them from adverse managed care decisions Non-Medicaid persons are covered by our individual contract with DCH and the Mental Health Code, although their rights are not as vast as those with Medicaid Non-Medicaid persons are covered by our individual contract with DCH and the Mental Health Code, although their rights are not as vast as those with Medicaid

What are actions Anything that involves limiting the services requested by a Medicaid person, for example: Anything that involves limiting the services requested by a Medicaid person, for example: Development of a treatment plan noting duration, frequency, etc. of servicesDevelopment of a treatment plan noting duration, frequency, etc. of services Changing services – either the type, duration, frequency, etc.Changing services – either the type, duration, frequency, etc. Terminating servicesTerminating services Not providing services within 14 daysNot providing services within 14 days Not providing timely decisions relative to servicesNot providing timely decisions relative to services

What do you do in the event of an action? You provide a notice to let the consumer know what they can do to contest the action. You provide a notice to let the consumer know what they can do to contest the action. Medicaid people receive our Notice of Action for Medicaid BeneficiariesMedicaid people receive our Notice of Action for Medicaid Beneficiaries Non-Medicaid people receive our Notice of Action for Non-MedicaidNon-Medicaid people receive our Notice of Action for Non-Medicaid An explanation of the grievance system is within the Venture Medicaid Handbook and the Pines Consumer Handbook, both given at intakeAn explanation of the grievance system is within the Venture Medicaid Handbook and the Pines Consumer Handbook, both given at intake

Advanced vs. Adequate Notices Advanced – you need to give notice prior to the action that involves their services. The form needs to be mailed at least 12 calendar days before the action. Advanced – you need to give notice prior to the action that involves their services. The form needs to be mailed at least 12 calendar days before the action. Adequate – you need to give the notice at the time of the decision, for example: Adequate – you need to give the notice at the time of the decision, for example: Development of treatment plan and any addendumsDevelopment of treatment plan and any addendums Time that service is denied (including inpatient)Time that service is denied (including inpatient) At the time that both you and the client have agreed to service changes (make sure you document this agreement)At the time that both you and the client have agreed to service changes (make sure you document this agreement)

Notice Requirements Federal law requires certain things to be on the form. Federal law requires certain things to be on the form. - Our forms are in compliance with these requirements, but you should know that a person who wants to contest an action can: Contact Customer Services (Shirley) and/or Contact Customer Services (Shirley) and/or Contact Recipient Rights (Norma) and/or Contact Recipient Rights (Norma) and/or Contact DCHs Administrative Tribunal (contact numbers on the notice forms) Contact DCHs Administrative Tribunal (contact numbers on the notice forms) (The Medicaid person can do all of the above in any order or concurrently if they choose.)

One Caveat... Only Medicaid beneficiaries have the right to contact the Administrative Tribunal for a Medicaid Fair Hearing! Non-Medicaid people must go through recipient rights as their last step and appeal any decisions they dont like through the recipient rights committee.

Second Opinions Second opinions are a Mental Health code requirement Second opinions are a Mental Health code requirement In addition to the Federal requirements of action notices, we are to give a second opinion notice when: In addition to the Federal requirements of action notices, we are to give a second opinion notice when: The person is denied Pines services at intakeThe person is denied Pines services at intake The person is denied inpatient servicesThe person is denied inpatient services To request a second opinion, the consumer must contact John Bolton. To request a second opinion, the consumer must contact John Bolton.

What Now? Please take the attached test, print results, and give to Sue Enos Please take the attached test, print results, and give to Sue Enos and and Please sign the training log located within each buildings break area. Please sign the training log located within each buildings break area.Thanks!