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

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.

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

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  1. Appeals and Grievances Understanding Actions, Notices and Second OpinionsPines Behavioral Health

  2. The Grievance System • 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: • Notices of Actions Regarding their Services • The Right to Request Medicaid Fair Hearings • Customer Service Departments • Recipient Rights Officers • Second Opinion Processes

  3. Medicaid vs. Non-Medicaid • 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

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

  5. 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. • Medicaid people receive our Notice of Action for Medicaid Beneficiaries • Non-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 intake

  6. 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. • Adequate – you need to give the notice at the time of the decision, for example: • Development of treatment plan and any addendums • 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)

  7. Notice Requirements • 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 Recipient Rights (Norma) and/or • Contact DCH’s 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.)

  8. 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 don’t like through the recipient rights committee.

  9. Second Opinions • 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: • The person is denied Pines services at intake • The person is denied inpatient services • To request a second opinion, the consumer must contact John Bolton.

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

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