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CUSTOMER SERVICES STANDARDS TRAINING. March 21, 2007. Welcome. This training will model the characteristics and the practices of a high quality customer services unit: Friendly, welcoming, open attitude A gate-”opener” rather than a gate-”keeper”

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  • This training will model the characteristics and the practices of a high quality customer services unit:
    • Friendly, welcoming, open attitude
    • A gate-”opener” rather than a gate-”keeper”
    • Customer services staff are systems navigators
    • Ready to help
    • Answers to your questions
  • The federal Balanced Budget Act (BBA) of 1997 was enacted after Congress heard critical testimony from managed care recipients:
    • Lack of information about providers
    • No choice of providers
    • Health care decisions were made by personnel without clinical training
    • No due process
background ii
Background, II
  • As a result, the BBA requires certain protections for beneficiaries enrolled in Medicaid health plans
  • The BBA requires that Medicaid health plans meet managed care standards
  • The BBA requires that external quality reviews of their compliance be done annually
background iii
Background, III
  • In Michigan, Medicaid Pre-paid inpatient health plans (PIHPs) were required to have customer service capacity by the 2002 Application for Participation (AFP) and by their contract with MDCH
  • AFP and MDCH contract had minimal description of expectations
  • PIHPs were expected to review and adhere to the BBA requirements and assure oversight and compliance by subcontractors to whom CS is delegated
background iv
Background, IV
  • The 2004 External Quality Review performed by Health Services Advisory Group (HSAG) found that most PIHPs did not meet the Standard VI “Customer Service” Standard VII “Grievance Process”, or Standard VIII “Enrollee Rights”
  • MDCH determined that since this was a wide-spread problem, Michigan standards for how a customer services unit should operate and uniform language for enrollee information should be developed
background v
Background, V
  • Process:
    • Workgroup of top performers & MDCH staff
    • Consulted with HSAG
    • Developed draft standards
    • Sought input from PIHPs, Recovery Council, QI Council and Customer Services staff
    • Revised per input
    • Submitted recommendations to QI Council: Approved standards on May 31, 2006; approved uniform language on July 26, 2006
    • Contract and Financial Issues Committee approved July 13, 2006
background vi
Background, VI
  • Therefore, standards are not negotiable
  • Front door: Welcome to Mental Health
    • Like a concierge service at a hotel
    • “Systems navigation” – link to the right people and right information
    • Not a replacement for case managers, supports coordinators or recipient rights advisors!
    • Not a substitute for emergency access
    • PIHP needs to clearly distinguish emergency phone # from CS phone #
preamble ii
Preamble, II
  • Standards are for PIHPs
  • If a PIHP delegates the customer services function to an affiliate CMHSP, substance abuse coordinating agency or provider network (e.g., MCPN): these standards apply to them also
  • PIHP retains the responsibility for oversight
customer service functions
Customer Service Functions
  • Welcome
  • Inform
  • Help with Benefits
  • Assist with Dissatisfaction
  • Report Problems
functions of customer services unit
Functions of Customer Services Unit
  • Welcome and Orient individuals to services and benefits available, and the provider network
  • Provide information about how to access mental health, primary health, and other community services
  • Help individuals with problems and inquiries regarding benefits
functions of customer services unit ii
Functions of Customer Services Unit, II
  • Assist people with and oversee local complaint and grievance processes
  • Track and report patterns of problem areas for the organization
standard 1
Standard #1
  • There shall be a designated unit called “Customer Services”
standard 2
Standard #2
  • There shall be at the PIHP a minimum of one FTE (full time equivalent) dedicated to customer services. If the function is delegated, affiliate CMHSPs, substance abuse coordinating agencies (CAs) and network providers, as applicable, shall have additional FTEs (or fractions thereof) as appropriate to sufficiently meet the needs of the people in the service area.
standard 3
Standard #3
  • There shall be a designated toll-free customer services telephone line and access to a TTY number. The numbers shall be displayed in agency brochures and public information material.
standard 4
Standard #4
  • Telephone calls to the customer services unit shall be answered by a live voice during business hours. Telephone menus are not acceptable. A variety of alternatives may be employed to triage high volumes of calls.
standard 5
Standard #5
  • The hours of customer service unit operations and the process for accessing information from customer services outside those hours shall be publicized.
standard 6
Standard #6
  • The customer handbook shall contain the state-required topics
standard 7
Standard #7
  • The Medicaid coverage name and the state’s description of each service shall be printed in the customer handbook.
standard 8
Standard #8
  • The customer handbook shall contain a date of publication and revision(s).
standard 9
Standard #9
  • Affiliate CMHSP, substance abuse coordinating agency, or network provider names, addresses, phone numbers, TTYs, E-mails, and web addresses shall be contained in the customer handbook.
standard 10
Standard #10
  • Information about how to contact the Medicaid Health Plans or Medicaid fee-for-service programs in the PIHP service area shall be provided in the handbook (actual phone numbers and addresses may be omitted and held at the customers services office due to frequent turnover of plans and providers)
standard 11
Standard #11
  • Customer services unit shall maintain current listings of all providers, both organizations and practitioners, with whom the PIHP has contracts, the service they provide, languages they speak, and any specialty for which they are known. This list must include independent person-centered planning facilitators. Beneficiaries shall be given this list initially and be informed annually of its availability.
standard 12
Standard #12
  • Customer services unit shall have access to information about the PIHP including CMHSP affiliate annual report, current organizational chart, CMHSP board member list, meeting schedule and minutes that are available to be provided in a timely manner to an individual upon request.
standard 13
Standard #13
  • Upon request, the customer services unit shall assist beneficiaries with the grievance and appeals, and local dispute resolution processes, and coordinate as appropriate with Fair Hearing Officers and the local Office of Recipient Rights.
standard 14
Standard #14
  • Customer services staff shall be trained to welcome people to the public mental health system and to possess current working knowledge in, and know where in the organization detailed information can be obtained on at least the following…
standard 14 a
Standard #14.a.
  • Information regarding the populations served (serious mental illness, serious emotional disturbance, developmental disability and substance use disorder) and eligibility criteria for various benefits plans (e.g., Medicaid, Adult Benefit Waiver, MIChild)
standard 14 b
Standard #14.b.
  • Service array (including substance abuse treatment services), medical necessity criteria, and eligibility for and referral to specialty services
standard 14 c
Standard #14.c.
  • Person-centered planning
standard 14 d
Standard #14.d.
  • Self-determination
standard 14 f
Standard #14.f.
  • Peer Specialists
standard 14 g
Standard #14.g.
  • Grievance and appeals, Fair Hearings, local dispute resolution processes, and Recipient Rights
standard 14 h
Standard #14.h.
  • Limited English Proficiency (LEP) and cultural competency
standard 14 i
Standard #14.i.
  • Information about Medicaid covered services and referral within PIHPs as well as outside to Medicaid Health Plans, Fee-for-Service practitioners, and Department of Human Services
standard 14 j the public mental health system
Standard #14.j: The Public Mental Health System
  • Structure
  • Funding
  • Services
  • Protections
general service structure
General Service Structure


Community Mental Health Services Programs (46CMHSPs)

Medicaid Prepaid Inpatient Heath Plans (18 PIHPs)


Each local CMHSP provides an array of Mental Health services through a network of providers to adults with SPMI, children with SED, persons with DD and persons with substance use disorders.


State taxes

Federal Medicaid

State Appropriations

Federal Block

Grant funding


County Mental Health


PIHP Medicaid


CMHSP - GF contract

CMHSP - PIHP Affiliate agreement


mental health code services
Mental Health Code Services

Within the available state funding …

priority for services shall be given to individuals with the most severe forms of serious mental illness , serious emotional disturbances and developmental disability, with priority to be given to those in urgent or emergency situations…

Persons who do not meet this threshold of severity may be put on waiting lists (or referred elsewhere) for services.

The public generally does not understand these financial and legal limitations to service.

medicaid mental health services
Medicaid Mental Health Services

Medicaid beneficiaries presenting with a specialty level of care are entitled to receive all “medically necessary covered services and supports from the CMHSP to treat, ameliorate, diminish or stabilize their mental health, developmental disability and substance abuse conditions.

recipient protections
Recipient Protections
  • The person centered planning process
  • The individualized plan of service
  • Dedicated local Customer Service/problem resolution staff
  • Local recipient rights protection system
  • Local dispute resolution process
  • Local Grievance and Appeal Process
  • And the Lansing-based Medicaid fair hearing process
standard 14 k
Standard #14.k.
  • Balanced Budget Act relative to customer services functions and beneficiary rights and protections
standard 14 l
Standard #14.l.
  • Community Resources (e.g., advocacy organizations, housing options, schools, public health agencies)
standard 14 m
Standard #14.m.
  • Public Health Code (for substance abuse treatment recipients if not delegated to the substance abuse coordinating agency)
customer services handbook
Customer Services Handbook
  • Each PIHP must provide a beneficiary an up-to-date handbook when they first come for services and periodically thereafter
  • There are BBA-required topics that must be in the handbook
  • There is MDCH-required language for some topics to ensure consistency across the state
  • PIHPs may tailor information to reflect their local operations and may add information to each template
customer services handbook ii
Customer Services Handbook, II
  • PIHPs that have quantity of handbooks on hand may give these out as long as they contain or are supplemented with the required information
  • Drafts of new handbooks must be available for review in the Spring 2007
  • New handbooks must be distributed beginning October 1, 2007
customer services handbook iii
Customer Services Handbook, III
  • There are 12 topics that require the use of template language.
  • They are not required to appear in this order
  • Template #1 Confidentiality and family access to information
  • Template #2 Coordination of Care
  • Template #3 Emergency and after-hours access to services
  • Template #4 Glossary
templates cont
Templates Cont….
  • Template #5 Grievance and Appeals
  • Template #6 Language Accessibility and Accommodations
  • Template #7 Payment for Services
  • Template #8 Person-Centered Planning
  • Template #9 Recipient Rights
templates cont53
Templates Cont….
  • Template #10 Recovery & Resiliency
  • Template #11 Service Array, Eligibility, Medical Necessity, and Choice of Providers in Network
  • Template #12 Service Authorization
other required handbook topics
Other Required Handbook Topics
  • How to access the PIHP or CMHSP
  • How to obtain access to out-of-network services
other required handbook topics ii
Other Required Handbook Topics, II
  • Affiliate [for Detroit-Wayne, the MCPNs] addresses and phone numbers
  • Executive director
  • Medical director
  • Recipient Rights officer
  • Customer Services address & phone number, what it can do for customer
other required handbook topics iii
Other Required Handbook Topics, III
  • Community Resource list (includes advocacy organizations such as NAMI, ISD, ARC, etc.)
  • Index
  • Right to information about PIHP operations (org chart, annual report, etc)
  • Services not covered under contract
  • Welcome to PIHP
other suggested handbook topics iv
Other Suggested Handbook Topics, IV
  • Customer services phone number in the footer of each page
  • Safety information (ex: no weapons)