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

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!