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Home My WebLink Aboutconsumer-grievance-and-appeal-process-info.-english-v.-2025_ko_kr 2025 년 6 월 페이지 1 / 4 GRIEVANCE AND APPEALS PROCESS If you have a concern or problem or are not satisfied with your behavioral health services, the Behavioral Health Plan (BHP) wants to be sure your concerns are resolved simply and quickly. You or your representative may file a Grievance or Appeal with the Consumer Assistance office at 1(800) 779-0787. You may also ask your provider if they have a process for resolving grievances. Please use the Grievance and Appeal Request Form to file a Grievance or to request an Appeal. Please note that appeals may only be filed with Consumer Assistance and not with your provider. You will not be subject to discrimination or any other penalty for filing a Grievance or Appeal. A Grievance is defined as an expression of dissatisfaction about any matter regarding your behavioral health services that are not one of the problems covered by the Appeal and State Fair Hearing processes described below. Examples of grievances might be as follows: the quality of care of services provided, aspects of interpersonal relationships – such as rudeness of an employee, etc. Steps to file a Grievance: • File a Grievance orally or in writing. Oral grievances do not have to be followed up in writing. You may authorize another person to act on your behalf. • You may file a Grievance at any time. • You will receive a written acknowledgement of receipt of your Grievance postmarked within 5 days of receipt of the Grievance. • The BHP has 30 calendar days after the receipt of your Grievance to review it and notify you or your representative in writing about the decision. If resolution of your grievance is not reached within 30 calendar days, you will be provided prompt oral and/or written notification of your rights and specific information on your grievance. Where to File Your Grievance with Alameda County Behavioral Health Department (ACBHD): By phone: 1-800-779-0787 Consumer Assistance For assistance with hearing or speaking, call 711, California Relay Service Via US Mail: 2000 Embarcadero Cove, Suite 400, Oakland, CA 94606 In Person: By visiting Consumer Assistance at Mental Health Association, 2855 Telegraph Ave, Suite 501, Berkeley, CA 94705 With your provider: Your provider may resolve your grievance internally or direct you to ACBHD above. You may obtain forms and assistance from your provider. An Appeal is a review by the BHP of an Adverse Benefit Determination (ABD). An Adverse Benefit Determination is defined to mean any of the following actions taken by the BHP or 2025 년 6 월 페이지 2 / 4 a BHP-contracted provider regarding Medi-Cal behavioral health care services: 1) The denial or limited authorization of a requested service, including determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit; 2)The reduction, suspension, or termination of a previously authorized service; 3) The denial, in whole or in part, of payment for a service; 4) The failure to provide services in a timely manner; 5) The failure to act within the required timeframes for standard resolution of grievances and appeals; or 6) The denial of a beneficiary’s request to dispute financial liability. The decision made by the BHP about your behavioral health services may be described in a Notice of Adverse Benefit Determination (NOABD) letter sent or given personally to you. 이의 제기 신청 단계: • 이의 제기는 회원, 서비스 제공자 및/또는 권한을 위임받은 대리인이 구두 또는 서면으로 신청할 수 있습니다. 회원을 대신하여 서비스 제공자가 신청하는 이의 제기에는 해당 회원의 서면 동의가 필요합니다. • NOABD 를 받은 날짜로부터 60 일 이내에 직접, 전화 또는 서면으로 이의 제기를 신청하십시오. 구두로 이의 제기를 신청하는 경우, 이후에 서명이 있는 이의 제기 신청서를 제출해야 합니다. NOABD 를 받지 못한 경우, 제출 마감일은 없습니다. 따라서 언제든지 신청할 수 있습니다. 귀하는 다른 사람이 귀하를 대신하여 절차를 수행하도록 위임할 수 있습니다. • 요청에 따라, NOABD 가 송달되거나 귀하가 수령한 날로부터 10 일 이내에 이의 제기를 신청하면 이의 제기가 보류 중인 동안 귀하의 혜택은 계속 유지됩니다. • 이의 제기 접수 후 역일 5 일 이내에 소인이 찍힌 이의 제기 접수 확인서를 서면으로 받게 됩니다. • BHP 는 귀하의 이의 제기 사항을 접수한 날로부터 30 일 이내에 이를 검토하고 귀하나 귀하의 대리인에게 결정에 대해 서면으로 통지해야 합니다. 이 기간 동안 귀하는 증거 및 증언을 제시하는 등 구두 또는 서면으로 증빙 자료를 제출하고 법적 및 사실적 주장을 할 수 있습니다. • 수혜자가 고충 처리 결과에 만족하지 않는 경우, 이의 제기를 할 수 없습니다. 2025 년 6 월 페이지 3 / 4 An Expedited Appeal can be requested if you think waiting 30 days could seriously jeopardize your mental health or substance use disorder condition and/or your ability to attain, maintain or regain maximum function. If the BHP agrees that your appeal meets the requirements for an Expedited Appeal, the BHP will resolve it within 72 hours after the Expedited Appeal is received. Steps to file an Expedited Appeal: • File an Expedited Appeal in person, on the phone or in writing within 60 days of the date of a Notice of Adverse Benefit Determination (NOABD). Verbal and in person requests for Expedited Appeals do not have to be put in writing. You may authorize another person to act on your behalf. • Upon request, your benefits will continue while the Expedited Appeal is pending IF you file the Appeal within 10 calendar days from the date the NOABD was mailed or given to you. • The BHP has 72 hours after the receipt of your Expedited Appeal to review it and notify you or your representative in a written Notice of Appeal Resolution (NAR) and may notify you verbally as well. During this time, you may provide verbal or written supporting documentation including presenting evidence and testimony and make legal and factual arguments. • If the BHP decides that your appeal does not qualify for an Expedited Appeal, they will notify you right away verbally and in writing within 2 calendar days. Your appeal will then follow the Standard Appeal process. Where to File Your Appeal with ACBHD: By Phone: 1-800-779-0787 Consumer Assistance For assistance with hearing or speaking, call 711, California Relay Service Via US Mail: 2000 Embarcadero Cove, Suite 400, Oakland, CA 94606 In Person: By visiting Consumer Assistance at Mental Health Association, 2855 Telegraph Ave, Suite 504, Berkeley, CA 94705 You have the right to a State Fair Hearing, an independent review conducted by the California Department of Social Services, if you have completed the BHP’s Appeals process and the problem is not resolved to your satisfaction. A request for a State Fair Hearing is included with each Notice of Appeal Resolution (NAR); you must submit the request within 120 days of the postmark date or the day that the BHP personally gave you the NAR. You may request a State Fair Hearing whether or not you have received a NOABD. To keep your same services while waiting for a hearing, you must request the hearing within ten (10) days from the date the NAR was mailed or personally given to you or before the effective date of the change in service, whichever is later. The State must reach its decision within 90 calendar days of the date of request for Standard Hearings and for 2025 년 6 월 페이지 4 / 4 Expedited Hearings within 3 days of the date of request. The BHP shall authorize or provide the disputed services promptly within 72 hours from the date it receives notice reversing the BHP’s ABD. You may request a State Fair Hearing by calling 1(800) 952-5253, or for TTY: 711, online to https://secure.dss.cahwnet.gov/shd/pubintake/cdss-request.aspx or writing to: California Department of Social Services/State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430. For more detailed information on the Grievance or Appeals process, please ask your provider for a copy of Guide to Medi-Cal Mental Health Services OR Guide to Drug Medi-Cal Services. For questions or assistance with filling out forms, you may ask your provider or call: Consumer Assistance: 1 (800) 779-0787