How to File a Grievance or Appeal for Specialty Mental Health
What Is the Grievance Process?
The grievance process will:
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Involve simple, and easily understood procedures that allow you to present your grievance orally or in writing.
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Not count against you or your provider in any way.
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Allow you to authorize another person to act on your behalf, including a provider or advocate. If you authorize another person to act on your behalf, the mental health plan might ask you to sign a form authorizing the mental health plan to release information to that person.
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Ensure that the individuals making the decisions are qualified to do so and not involved in any previous levels of review or decision-making.
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Identify the roles and responsibilities of you, your mental health plan and your provider.
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Provide resolution for the grievance in the required timeframes.
When Can I File a Grievance?
You can file a grievance anytime with the mental health plan if you are unhappy with the specialty mental health services or have another concern regarding the mental health plan.
How Can I File a Grievance?
You may call your mental health plan 1-888-530-8688 to get help with a grievance. Grievances can be filed orally or in writing. Oral grievances do not have to be followed up in writing. If you want to file your grievance in writing, the mental health plan will provide self-addressed envelopes at all provider sites for you to mail in your grievance. If you do not have a self-addressed envelope, you may mail your grievance directly to the address that is provided on the front of this handbook.
How Do I Know If the Mental Health Plan Received My Grievance?
Your mental health plan is required to let you know that it received your grievance by sending you a written confirmation within 5 calendar days of receipt. A grievance received over the phone or in person, that you agree is resolved by the end of the next business day, is exempt and you may not get a letter.
When Will My Grievance Be Decided?
The mental health plan must make a decision about your grievance within 90 calendar days from the date you filed your grievance. The timeframes for making a decision may be extended by up to 14 calendar days if you request an extension, or if the mental health plan believes that there is a need for additional information and that the delay is for your benefit. An example of when a delay might be for your benefit is when the mental health plan believes it might be able to resolve your grievance if they have more time to get information from you or other people involved
How Do I Know If the Mental Health Plan Has Made a Decision About My Grievance?
When a decision has been made regarding your grievance, the mental health plan will notify you or your representative in writing of the decision. If your mental health plan fails to notify you or any affected parties of the grievance decision on time, then the mental health plan is required to provide you with a Notice of Adverse Benefit Determination advising you of your right to request a State Fair Hearing. Your mental health plan is required to provide you with a Notice of Adverse Benefit Determination on the date the timeframe expires. You may call the mental health plan for more information if you do not receive a Notice of Adverse Benefit Determination.
Is There a Deadline to File a Grievance?
No, you may file a grievance at any time
THE APPEAL PROCESS (STANDARD AND EXPEDITED)
Your mental health plan must allow you to challenge a decision by your mental health plan that you do not agree with and request a review of certain decisions made by the mental health plan or your providers about your specialty mental health services. There are two ways you can request a review. One way is using the standard appeal process. The other way is by using the expedited appeal process. These two types of appeals are similar; however, there are specific requirements to qualify for an expedited appeal. The specific requirements are explained below.
What Is a Standard Appeal?
A standard appeal is a request for review of a decision made by the mental health plan or your provider that involves a denial or changes to services you think you need. If you request a standard appeal, the mental health plan may take up to 30 days to review it. If you think waiting 30 days will put your health at risk, you should ask for an “expedited appeal.”
The standard appeal process will:
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Allow you to file an appeal orally or in writing.
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Ensure filing an appeal will not count against you or your provider in any way.
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Allow you to authorize another person to act on your behalf, including a provider. If you authorize another person to act on your behalf, the mental health plan might ask you to sign a form authorizing the mental health plan to release information to that person.
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Have your benefits continued upon request for an appeal within the required timeframe, which is 10 days from the date your Notice of Adverse Benefit Determination was mailed or personally given to you. You do not have to pay for continued services while the appeal is pending. However, if you do request continuation of the benefit, and the final decision of the appeal confirms the decision to reduce or discontinue the service you are receiving, you may be required to pay the cost of services provided while the appeal was pending.
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Ensure that the individuals making the decision on your appeal are qualified to do so and not involved in any previous level of review or decision-making.
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Allow you or your representative to examine your case file, including your medical record, and any other documents or records considered during the appeal process.
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Allow you to have a reasonable opportunity to present evidence and testimony and make legal and factual arguments, in person, or in writing.
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Allow you, your representative, or the legal representative of a deceased beneficiary’s estate to be included as parties to the appeal.
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Let you know your appeal is being reviewed by sending you written confirmation.
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Inform you of your right to request a State Fair Hearing, following the completion of the appeal process with the mental health plan.
When Can I File an Appeal?
You can file an appeal with your mental health plan in any of the following situations:
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The mental health plan or one of the contracted providers decides that you do not qualify to receive any Medi-Cal specialty mental health services because you do not meet the access criteria.
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Your provider thinks you need a specialty mental health service and asks the mental health plan for approval, but the mental health plan does not agree and denies your provider’s request, or changes the type or frequency of service.
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Your provider has asked the mental health plan for approval, but the mental health plan needs more information to make a decision and doesn’t complete the approval process on time.
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Your mental health plan does not provide services to you based on the timelines the mental health plan has set up.
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You don’t think the mental health plan is providing services soon enough to meet your needs.
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Your grievance, appeal, or expedited appeal wasn’t resolved in time.
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You and your provider do not agree on the specialty mental health services you need.
How Can I File an Appeal?
You may call your mental health plan at 1-888-530-8688 to get help filling an appeal. The mental health plan will provide self-addressed envelopes at all provider sites for you to mail in your appeal. If you do not have a self-addressed envelope, you may mail your appeal directly to the address in the front of this handbook or you may submit your appeal by e-mail to LCBH@co.lassen.ca.us or fax to 530-251-8394.
How Do I Know If My Appeal Has Been Decided?
Your mental health plan will notify you or your representative in writing about their decision for your appeal. The notification will have the following information:
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The results of the appeal resolution process
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The date the appeal decision was made
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If the appeal is not resolved completely in your favor, the notice will also contain information regarding your right to a State Fair Hearing and the procedure for filing a State Fair Hearing
Is There a Deadline to File an Appeal?
You must file an appeal within 60 days of the date on the Notice of Adverse Benefit Determination. There are no deadlines for filing an appeal when you do not get a Notice of Adverse Benefit Determination, so you may file this type of appeal at any time
When Will a Decision Be Made About My Appeal?
The mental health plan must decide on your appeal within 30 calendar days from when the mental health plan receives your request for the appeal. The timeframes for making a decision may be extended up to 14 calendar days if you request an extension, or if the mental health plan believes that there is a need for additional information and that the delay is for your benefit. An example of when a delay is for your benefit is when the mental health plan believes it might be able to approve your appeal if it has more time to get information from you or your provider.
What If I Can’t Wait 30 Days for My Appeal Decision?
The appeal process may be faster if it qualifies for the expedited appeal process.
What Is an Expedited Appeal?
An expedited appeal is a faster way to decide on an appeal. The expedited appeal process follows a similar process to the standard appeal process. However, you must show that waiting for a standard appeal could make your mental health condition worse. The expedited appeal process also follows different deadlines than the standard appeal. The mental health plan has 72 hours to review expedited appeals. You can make a verbal request for an expedited appeal. You do not have to put your expedited appeal request in writing.