HomeMy WebLinkAboutconsumer-grievance-and-appeal-process-info.-english-v.-2025_tl_ph
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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
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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.
Mga hakbang sa paghahain ng Apela:
• Maaaring maghain ng apela ang isang miyembro, o isang provider at/o awtorisadong
kinatawan, nang pasalita o nakasulat. Ang mga apelang inihain ng provider sa
ngalan ng miyembro ay nangangailangan ng nakasulat na pahintulot mula sa
miyembro.
• Maghain ng Apela nang personal, sa telepono o nakasulat sa loob ng 60 araw mula
sa petsa ng NOABD. Kung maghahain ka ng Apela nang pasalita, kailangan mo itong
sundan ng isang nakasulat at nilagdaang Apela. Kung hindi mo natanggap ang
NOABD, walang itinakdang deadline para sa paghahain; kaya maaari kang maghain
anumang oras. Maaari mong awtorisahan ang ibang tao na kumilos para sa iyo.
• Kung hihilingin, magpapatuloy ang iyong mga benepisyo habang nakabinbin ang
Apela kung ihahain mo ang Apela sa loob ng 10 araw sa kalendaryo mula sa petsa
ng pagpapadala o pagbibigay sa iyo ng NOABD.
• Makakatanggap ka ng nakasulat na kumpirmasyon ng pagtanggap ng iyong Apela na
may postmark sa loob ng 5 araw sa kalendaryo mula sa pagtanggap ng Apela.
• Mayroong 30 araw sa kalendaryo ang BHP mula sa pagtanggap ng iyong Apela
upang suriin ito at ipaalam sa iyo o sa iyong kinatawan nang nakasulat ang tungkol
sa desisyon. Sa panahong ito, maaari kang magbigay ng pasalita o nakasulat na
sumusuportang dokumentasyon kabilang ang paghaharap ng ebidensya at
testimonya, at maglahad ng mga legal at totoong argumento.
• Ang mga Apela ay hindi puwede para sa mga benepisyaryo na hindi nasisiyahan sa
kinalabasan ng isang karaingan.
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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
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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