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					                              Enrollee Grievance Report Template
                         RBHA
                          GSA
Month/Year Resolutions Occurred
Enrollee Grievance Report Template
                                      Enrollee Grievance Report

                                         Instructions - Column Headings:
A. Total Received: Total number of grievances related to each subclassification during the month beginning on the
first (1st) calendar day and ending on the last.
B. Total Resolved: Total number of grievances that were closed through verbal or written methods based on
research and response during the month beginning on the first (1st) calendar day and ending on the last.
C. First Contact Resolution: Total number of grievances resolved at the time of receipt.
D. 1-10 Days: Total number of grievances resolved within ten (10) days of receipt.
E. 11- 30 Days: Total number of grievances resolved in more than ten (10) days, but less than thirty-one (31) days.
F. 31-60 Days: Total number of grievances resolved in more than than thirty (30) days, but less than sixty-one (61)
G. 61-90 Days: Total number of grievances resolved in more than sixty (60) days, but less than ninety-one (91)
days. Subtracting the totals from each of the timeframe columns from the Total Resolved column will leave the
reviewer with those grievances that were resolved in more than one (1) quarter from receipt.
    Address any delayed resolutions (greater than 90 days) here:




H. Average Time to Resolve (ATR): Sum of days to resolve each case individually divided by column B, Total
I. Previous Month's ATR: Column H from report submitted for previous month.
J. Current Month from Previous Year ATR: Column H submitted for the coinciding month in the previous year.
K. (ROW) Summary Totals of each column: Please sum columns A through J appropriately at the bottom of each
column as defined by row K.
                                           Descriptions of Tab Categories:
Transportation – Complaints made by a member or advocate related to the provision of non-emergent
transportation services; which can either be related to timeliness or service level. At present Transportation
Medical Service Provision – Complaints made by a member or advocate related to the service received from a
provider/doctor/facility; which include behavioral and physical plant complaints. These do not include Quality of
Care concerns that are reviewed through the quality and peer review processes or Access to Care complaints as
defined below. Include these ADHS Complaint Categories in the Medical Service Provision list: Clinical Decisions
Contractor/Program Contractor Service Level – Any complaint made by a member/advocate relating to the
Contractor’s administrative processes or behavior of contractor staff members. Include these ADHS Complaint
Categories in the Contractor Service Level list: Customer Service, Information Sharing, Financial.
Access to Care – Reported separately from Medical Service Provision (above). Access to care complaints are
those complaints received from members/advocates relating to the inability to obtain an appointment; the length of
time between a request for appointment and fulfillment; and/or the lack of available providers (PCP or specialists).
Include the ADHS Complaint Category Access to Services in the Access to Care list.
                                                      Enrollee Grievance Report                                        Attachment C


                                                                                                                   J. Current
                                                                                                                   Month's
Enrollee Grievance                                                                         H. Average   I.         ATR for
                                              C. First                                     Time to      Previous   Previous
Summary:                    A. Total B. Total Contact    D.1-10 E. 11-30 F. 31-60 G. 61-90 Resolve      Month's    Calendar
Transportation              Received Resolved Resolution Days Days       Days     Days     (ATR)        ATR        Year

Transportation                      0         0            0       0        0        0   0
K. Summary Totals of each
column                              0         0            0       0        0        0   0




                                                  Grievance System Reporting Guide
                                                           Enrollee Grievance Report                                         Attachment D


                                                                                                                      J. Current
                                                                                                   H.                 Month's
Enrollee Grievance                                                                                 Average   I.       ATR for
                                                      C. First                                     Time to   Previous Previous
Summary: Medical                    A. Total B. Total Contact    D.1-10 E. 11-30 F. 31-60 G. 61-90 Resolve   Month's Calendar
Service Provision                   Received Resolved Resolution Days Days       Days     Days     (ATR)     ATR      Year
Denial of Service                           0        0           0         0       0    0       0
Reduction, Suspension, or
Termination of Services                     0        0           0         0       0    0       0
SMI Eligibility                             0        0           0         0       0    0       0
SMI De-certification
                                            0        0           0         0       0    0       0
Assessment/Service Plan Content
                                            0        0           0         0       0    0       0
Lack of Service Plan
                                            0        0           0         0       0    0       0
Diagnosis
                                            0        0           0         0       0    0       0
Medications
                                            0        0           0         0       0    0       0
Court Ordered Treatment
                                            0        0           0         0       0    0       0
Cultural Issues
                                            0        0           0         0       0    0       0
Concern about Client’s Well-being
                                            0        0           0         0       0    0       0
Confidentiality
                                            0        0           0         0       0    0       0
Restraint/Seclusion
                                            0        0           0         0       0    0       0
Sexual Abuse
                                            0        0           0         0       0    0       0
Physical Abuse
                                            0        0           0         0       0    0       0



                                                                     Page 5 of 9
                                                        Enrollee Grievance Report                                         Attachment D


                                                                                                                   J. Current
                                                                                                H.                 Month's
Enrollee Grievance                                                                              Average   I.       ATR for
                                                   C. First                                     Time to   Previous Previous
Summary: Medical                 A. Total B. Total Contact    D.1-10 E. 11-30 F. 31-60 G. 61-90 Resolve   Month's Calendar
Service Provision                Received Resolved Resolution Days Days       Days     Days     (ATR)     ATR      Year
Exploitation
                                         0        0           0         0       0    0       0
Mistreatment
                                         0        0           0         0       0    0       0
Verbal Abuse
                                         0        0           0         0       0    0       0
Dangerous Condition
                                         0        0           0         0       0    0       0
Other – Rights Violation
                                         0        0           0         0       0    0       0
Unlawful Conduct by a Provider
                                         0        0           0         0       0    0       0
Mortality
                                         0        0           0         0       0    0       0
Lack of Required Notice
                                         0        0           0         0       0    0       0
Service Contingency
                                         0        0           0         0       0    0       0
Coordination Between Health
Care Systems                             0        0           0         0       0    0       0
Continuity of Care
                                         0        0           0         0       0    0       0
Inter-RBHA Transfer
                                         0        0           0         0       0    0       0
Intra-RBHA Transfer
                                         0        0           0         0       0    0       0
MMA Issues
                                         0        0           0         0       0    0       0




                                                                  Page 6 of 9
                                                   Enrollee Grievance Report                                         Attachment D


                                                                                                              J. Current
                                                                                           H.                 Month's
Enrollee Grievance                                                                         Average   I.       ATR for
                                              C. First                                     Time to   Previous Previous
Summary: Medical            A. Total B. Total Contact    D.1-10 E. 11-30 F. 31-60 G. 61-90 Resolve   Month's Calendar
Service Provision           Received Resolved Resolution Days Days       Days     Days     (ATR)     ATR      Year
Prior Authorization
                                    0        0           0         0       0    0       0
K. Summary Totals of each
column                              0        0           0         0       0    0       0




                                                             Page 7 of 9
                                                                Enrollee Grievance Report                                                  Attachment E



Enrollee Grievance
Summary:                                                                                          H. Average               J. Current
                                                     C. First                                     Time to    I. Previous   Month's ATR
Contractor Service                 A. Total B. Total Contact    D.1-10 E. 11-30 F. 31-60 G. 61-90 Resolve    Month's       for Previous
Level                              Received Resolved Resolution Days Days       Days     Days     (ATR)      ATR           Calendar Year
Unable to contact RBHA staff/not
receiving return calls.                    0         0          0      0        0           0   0
Unable to contact Provider
staff/not receiving return calls           0         0          0      0        0           0   0
Needs information about
services/procedures                        0         0          0      0        0           0   0
Appointment Cancelled without
Notice                                     0         0          0      0        0           0   0
Flexibility of Agency Service
Hours                                      0         0          0      0        0           0   0
Staffing Pattern
                                           0         0          0      0        0           0   0
Other – No Rights Violation
                                           0         0          0      0        0           0   0
Fees/Co-pays
                                           0         0          0      0        0           0   0
Claims
                                           0         0          0      0        0           0   0
Billing
                                           0         0          0      0        0           0   0
Claim Payment
                                           0         0          0      0        0           0   0
Entitlements
                                           0         0          0      0        0           0   0
Request for Medical Records
                                           0         0          0      0        0           0   0
Family Involvement
                                           0         0          0      0        0           0   0
Restrict Access to Health
Information                                0         0          0      0        0           0   0
K. Summary Totals of each
column                                     0         0          0      0        0           0   0



                                                            Grievance System Reporting Guide
                                                                                                                                  J.
                                                                                                                                  Current
                                                                                                               H.                 Month's
Enrollee Grievance                                                                                             Average   I.       ATR for
                                                 C. First                                                      Time to   Previous Previous
Summary: Access                A. Total B. Total Contact                E. 11-30 F. 31-60       G. 61-90       Resolve   Month's Calendar
to Care                        Received Resolved Resolution D.1-10 Days Days     Days           Days           (ATR)     ATR      Year
No Provider to Meet Needs              0        0           0          0        0           0              0
Wait List                              0        0           0          0        0           0              0
Timeliness                             0        0           0          0        0           0              0
Office/Appointment Wait Time           0        0           0          0        0           0              0
Episode of Care (EOC)                  0        0           0          0        0           0              0
Authorization Process                  0        0           0          0        0           0              0
K. Summary Totals of each
column                                 0        0           0          0        0           0              0

				
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