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Responding Successfully to a Denial of Service

Responding Successfully to a Denial of Service. Hint: Time is on your side. The Grievance & Appeal process. 1 st level grievance (2 nd opinion) 2 nd level grievance (Panel review) 3 rd level grievance (Health Dept) 4 th level grievance ( DPW Fair Hearing)

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Responding Successfully to a Denial of Service

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  1. Responding Successfully to a Denial of Service Hint: Time is on your side.

  2. The Grievance & Appeal process • 1st level grievance (2nd opinion) • 2nd level grievance (Panel review) • 3rd level grievance (Health Dept) • 4th level grievance (DPW Fair Hearing) • 5th level grievance (CMS appeal) (An authorization runs 120 days)

  3. 1st level grievance:The MCO “second opinion” • 8 or 9 days after the date on your first Denial of Service letter, request a 1st level grievance. • This keeps the same level of service going during the grievance process. 10

  4. 1st level grievance:The MCO “second opinion” • A second MCO reviewer looks over the first MCO reviewer’s work, to see if they agree or disagree (they rarely disagree). • This keeps the same level of service going during the grievance process. 15

  5. 2nd level grievance:The MCO “Panel Review” • 8 or 9 days after receiving the 2nd Denial of Service letter, request an appeal of the decision. • This keeps the same level of service going during the appeal process. 25

  6. 2nd level grievance:The MCO “Panel Review” • Ask to be included in the appeal meeting, and request the meeting to be held 20 days after the date of your appeal request. • This keeps the same level of service going during the appeal process. 50

  7. 3rd level grievance:The Health Department review • 8 or 9 days after the date on your second Denial of Service letter, request a 3rd level grievance. • This keeps the same level of service going during the grievance process. 65

  8. 3rd level grievance:The Health Department review • Ask to be included in the appeal meeting, and request the meeting to be held 20 days after the date of your appeal request. • This keeps the same level of service going during the appeal process. 90

  9. 4th level grievance:The DPW “fair hearing” • 8 or 9 days after the date on your second Denial of Service letter, request a 3rd level grievance. • This keeps the same level of service going during the grievance process. 100

  10. 4th level grievance:The DPW “fair hearing” • Ask to be included in the appeal meeting, and request the meeting to be held 20 days after the date of your appeal request. • This keeps the same level of service going during the appeal process. 125

  11. Win or Lose • Your child wins. Auth ends @ 120 days Days in appeal: 125

  12. The Absolute Basics • A life-domainpsychological evaluation is absolutely necessary. • A good Behavior Specialist Consultant is indispensible. • Neither is of any use without DATA.

  13. Documenting what is necessary • Dangerous to self or others? • Destructive to property of substantial value? • Severely disruptive to own or others’ lives?

  14. Documenting what is necessary • Frequency (how often does it happen?) • Intensity (how severe is it?) • Duration(how long has it been going on or how long do typical episodes last?)

  15. Documenting what is necessary • Evidence of Collaboration • Pediatrician or Psychiatrist involvement • School involvement and active support • Home and Community supports available • Thorough and complete Treatment Plan

  16. Competent professionals do more than give opinions… • They know the “rules” that the MCOs operate under and, • They do what is necessary to get their treatment recommendations implemented.

  17. Thank you. John Cappo Clinical Coordinator The Institute for Behavior Change www.ibc-pa.org

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