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CONCERNS_ COMPLAINTS_ DISPUTES_ GRIEVANCES_ AND APPEALS

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					COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                        Page 1 of 19


I.     PURPOSE: To establish a fair and efficient process for resolving complaints regarding services
       and supports managed and/or delivered by Community Mental Health for Central Michigan and
       its contract providers.

II.    APPLICATION: The provisions stated herein apply to all consumers of service from the
       Community Mental Health for Central Michigan provider network.

III.   REFERENCES:
       A. MDCH Managed Mental Health Care Grievance and Appeal Technical Requirement
          (MDCH/PIHP Contract, Attachment P6.3.2.1)
       B. CMHSP Appeal and Grievance Resolution Processes Technical Requirement
          (MDCH/CMHSP, Attachment C.6.3.2.1)
       C. MDCH Medical Services Administration Bulletin, Beneficiary Eligibility Manual, Beneficiary
          Hearings Chapter 1, Section 2.
       D. Michigan Department of Community Health Medical Services Administration, Community
          Mental Health Services Program Manual, Chapter III, page 3.
       E. Balanced Budget Act of 1997 Subpart F – Grievance System

IV.    DEFINITIONS:

        A. ACTION:                                       A decision that adversely impacts a
                                                         consumer’s claim for services due to:
                                                           Denial or limited authorization of a
                                                              requested service, including the type or
                                                              level of service.
                                                           Reduction, suspension, or termination of
                                                              a previously authorized service.
                                                           Denial, in whole or in part, of payment for
                                                              a service.
                                                           Failure to make a standard authorization
                                                              decision and provide notice about the
                                                              decision within 14 calendar days from the
                                                              date of receipt of a standard request for
                                                              service.
                                                           Failure to make an expedited
                                                              authorization decision within three (3)
                                                              working days from the date of receipt of a
                                                              request for expedited service
                                                              authorization.
                                                           Failure to provide services within 14
                                                              calendar days of the start date agreed
                                                              upon during the person-centered
                                                              planning process and as authorized by
                                                              CMHCM.
                                                           Failure of CMHCM to act within 45
                                                              calendar days from the date of a request
                                                              for a standard appeal.
                                                           Failure of CMHCM to act within three (3)
                                                              working days from the date of a request
                                                              for an expedited appeal.
                                                           Failure of CMHCM to provide disposition
                                                              and notice to a beneficiary of a local
                                                              grievance/complaint within 60 calendar
                                                              days of the date of the request.


        B. ADDITIONAL MENTAL HEALTH                   Supports and services available to Medicaid
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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           SERVICES                            beneficiaries who meet the criteria for specialty
                                               services and supports, under the authority of
                                               Section 1915(b)(3) of the Social Security Act.
                                               Also referred to as "B3" waiver services.

        C. ADEQUATE NOTICE:                    Provided to a consumer no later than the date of
                                               action when there is a denial of services,
                                               including hospitalization, or provided at the time
                                               the Person-Centered Plan (initially and with any
                                               changes) is signed.

        D. ADMINISTRATIVE HEARING/FAIR         An impartial review of a decision made by DCH
           HEARING:                            or CMH/contract agency that the beneficiary
                                               believes is inappropriate. The impartial review is
                                               completed by an Administrative Law Judge of the
                                               DCH Administrative Tribunal.

        E. ADMINISTRATIVE LAW JUDGE:           A person designated by the MDCH to conduct
                                               the hearing in an impartial or unbiased manner.

        F. ADVANCE NOTICE:                     Written notice advising the consumer of a
                                               decision to reduce, suspend or terminate
                                               services that are currently being provided. This
                                               notice shall be provided, or mailed to, the
                                               consumer at least 12 calendar days prior to the
                                               proposed date this action is to take effect.

        G. APPEAL:                             Request for review of an “action” as defined
                                               above.

        H. AUTHORIZED HEARING                  The person who stands in for or represents the
           REPRESENTATIVE:                     beneficiary in the hearing process and has the
                                               legal right to do so. This right comes from one of
                                               the following sources:
                                               1. Written authorization, signed by the
                                                    beneficiary, giving a person authority to act
                                                    for the beneficiary in the hearing process.
                                               2. Court appointed guardian or conservator.
                                               3. Parent with legal custody a minor child.
                                               4. The beneficiary's spouse, or the deceased
                                                    beneficiary's widow or widower, ONLY when
                                                    no one else has the authority to represent the
                                                    beneficiary.
                                               The Authorized Hearing Representative does not
                                               have a right to a hearing, but rather exercises the
                                               beneficiary's right. Someone who assists, but
                                               does not stand in for or represent the beneficiary
                                               in the hearing process, does not need to meet
                                               the above criteria.

        I. AUTHORIZATION OF SERVICES:          The processing of requests for initial and
                                               continuing service delivery.



        J. BENEFICIARY:                        An individual who has been determined eligible
                                               for Medicaid and who is receiving or may qualify
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                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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                                               to receive Medicaid services through CMHCM.

        K. CONSUMER:                           Broad, inclusive reference to an individual
                                               requesting or receiving mental health services
                                               delivered and/or managed by CMHCM, including
                                               Medicaid beneficiaries, and all others receiving
                                               CMHCM services.

        L. DENIAL:                             Refusal to authorize any CMHCM services to a
                                               new applicant for services or refusal to authorize
                                               additional services (more of the same service or
                                               new service) to a current consumer.

        M. EXPEDITED APPEAL:                   The expeditious review of an action, requested
                                               by a consumer or the consumer’s provider, when
                                               the time necessary for the normal appeal review
                                               process could seriously jeopardize the
                                               consumer’s life or health or ability to attain,
                                               maintain, or regain maximum function. If the
                                               consumer requests the expedited review,
                                               CMHCM determines if the request is warranted. If
                                               the consumer’s provider makes the request, or
                                               supports the consumer’s request, CMHCM must
                                               grant the request.

        N. GRIEVANCE:                          Consumer’s expression of dissatisfaction about
                                               CMHCM service issues, other than an action.
                                               Possible subjects for grievances include, but are
                                               not limited to, quality of care or services provided
                                               and aspects of interpersonal relationships
                                               between a service provider and the consumer.

        O. GRIEVANCE PROCESS:                  Impartial local level review of a Consumer’s
                                               grievance (expression of dissatisfaction) about
                                               CMHCM and/or its Provider Network service
                                               issues other than an action.

        P. GRIEVANCE SYSTEM:                   The overall local system of grievance and
                                               appeals required for consumers in the managed
                                               care context, including access to the fair hearing
                                               process for Medicaid beneficiaries.

        Q. INDEPENDENT REVIEWER                Person who was not directly involved in either the
                                               determination that led to an action or the situation
                                               that led to a grievance and who is also qualified
                                               to make an independent determination of the
                                               dispute. The first choice will be a supervisor from
                                               the same county where the grievance or appeal
                                               originated, and if none is available, then the
                                               program director from the same county, and then
                                               a program director in another county.



        R. LOCAL APPEALS PROCESS:              Impartial local level review of consumer’s appeal
                                               of an action presided over by individuals not
                                               involved with decision-making or previous level of
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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                                                       review.

        S. MEDICAID SERVICES:                          Services provided to a beneficiary under the
                                                       authority of the Medicaid State Plan, Habilitation
                                                       Services and Support waiver, and/or Section
                                                       1915(b)(3) of the Social Security Act.

        T. NOTICE OF DISPOSITION:                      Written statement of CMHCM’s decision for each
                                                       local appeal and/or grievance, provided to the
                                                       consumer.

        U. PROVIDER:                                   One that provides mental health services and/or
                                                       supports under contract with CMHCM.

        V. RECIPIENT RIGHTS COMPLAINT:                 Written or verbal statement by a consumer, or
                                                       anyone acting on behalf of the consumer,
                                                       alleging a violation of a Michigan Mental Health
                                                       Code protected right cited in Chapter 7, which is
                                                       resolved through the process established in
                                                       Chapter 7A.


V.     POLICY:

       A.   INTRODUCTION:
                        1.     All consumers have the right to a fair and efficient process for resolving
                               complaints regarding their services and supports managed and/or
                               delivered by Community Mental Health for Central Michigan and its
                               contract providers.
                        2.     A beneficiary of public mental health specialty services and supports
                               may access several options to pursue the resolution of a grievance or
                               appeal including the State Fair Hearing process, local appeal process
                               and the local grievance process regarding other service complaints. It is
                               important to note that these options may be pursued simultaneously. A
                               provider under contract with acting on behalf of the beneficiary and with
                               the beneficiary’s written consent may file an appeal.

       B.   The grievance and appeal processes for consumers shall promote the resolution of
            consumer concerns, as well as support and enhance the overall goal of improving the
            quality of care. The internal and external grievance and appeal processes shall include:
            1.     Service Authorization Decisions: When a service authorization is processed (initial
                   request or continuation of service delivery) shall provide the consumer written
                   service authorization decision within specified timeframes and as expeditiously as the
                   consumer’s health condition requires.
            2.     Notice Requirements: Notice shall be given whenever a Medicaid State Plan, waiver,
                   or alternative service is denied, reduced, suspended or terminated or when a service
                   authorization is not made timely. The notice shall be in writing and will be provided in
                   the language format needed by the individual to understand the content (i.e., the
                   format meets the needs of those with limited English proficiency, and/or limited
                   reading proficiency).



            3.    Continuation or Reinstatement of Services: shall continue or reinstate previously
                  authorized services while the local level and/or state level appeal are pending when
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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                  the consumer requests to have services continued or reinstated or the service were
                  ordered by an authorized provider.
            4.    Local Appeals Process: shall comply with Federal regulations to provide a
                  consumer with a local level appeal of an “action”. The local appeal process shall
                  include written notice of disposition for both standard and expedited resolutions
                  within applicable timeframes. Non-Medicaid consumers must be given notice of their
                  right to the MDCH Alternative Dispute Resolution process.
            5.    Local Grievance Process: shall provide consumers the right to a local grievance
                  process for issues that are not “actions”. Grievances may be filed at any time by a
                  consumer, guardian, or parent of a minor child or his/her legal representative. If
                  CMHCM fails to respond to a grievance within 60 calendar days, the grievance is
                  considered an “action” and a beneficiary is then entitled to a state fair hearing.
            6.    Record Keeping: shall maintain logs regarding appeals and grievances. Data shall
                  be made available to the quality improvement program for review and analysis.

VI.    PROCEDURE:
       A.  SERVICE AUTHORIZATION DECISIONS
           1.  Standard Authorization: Notice of the authorization decision must be provided as
               expeditiously as the consumer’s health condition requires, and no later than 14
               calendar days following receipt of a request for service. If the consumer or provider
               requests an extension or if Community Mental Health for Central Michigan (CMHCM)
               justifies, to Michigan Department of Community Health (MDCH) upon request, a need
               for additional information and how the extension is in the consumer’s interest;
               CMHCM may extend the 14 calendar day time period by up to 14 additional calendar
               days.
           2.  Expedited authorization: In cases in which a provider indicates, or CMHCM
               determines, that following the standard timeframe could seriously jeopardize the
               consumer’s life or health or ability to attain, maintain or regain maximum function,
               CMHCM must make an expedited authorization decision and provide notice of the
               decision as expeditiously as the consumer’s health condition requires, and no later
               than three (3) working days after receipt of the request for service.

                  If the consumer requests an extension, or if CMHCM justifies (to MDCH upon
                  request) a need for additional information and how the extension is in the consumer’s
                  best interest; CMHCM may extend the three (3) working day time period by up to 14
                  calendar days

                  When a standard or expedited authorization of services decision is extended,
                  CMHCM must give the consumer written notice of the reason for the decision to
                  extend the timeframe, and inform the consumer of the right to file an appeal if he or
                  she disagrees with that decision. CMHCM must issue and carry out its determination
                  as expeditiously as the enrollee's consumer’s health condition requires and no later
                  than the date the extension expires.

       B.   NOTICE REQUIREMENTS (Appendix A)
            1.  Notice of action requirements include:
                a. The requesting provider, in addition to the consumer, must be provided notice of
                    any decision by CMHCM to deny a service authorization request or to authorize a
                    service in an amount, duration or scope that is less than requested. The notice of
                    action to the provider is not required to be in writing.
                b. If the consumer or representative requests a local appeal or a beneficiary
                    requests a state fair hearing not more than 12 calendar days from the date of the
                    notice of action, CMHCM must reinstate with consumer approval the services
                    until disposition of the appeal.
                c. If the consumer’s services were reduced, terminated or suspended without an
                    advance notice, CMHCM must reinstate with consumer approval the services to
                    the level before the action
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                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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                  d.  If the utilization review function is not performed within an identified organization,
                      program or unit (access centers, prior authorization unit, or continued stay units),
                      any decision to deny, suspend, reduce, or terminate a service occurring outside
                      of the person-centered planning process still constitutes an action, and requires
                      a written notice of action.
            2.    Written Notice of Action (both Adequate and Advanced) must contain the following:
                  a. What action CMHCM has taken or intends to take.
                  b. The reason for the action.
                  c. The consumer’s or Provider’s right to file a local level appeal, and instructions for
                      doing so.
                  d. The beneficiary’s right to request a State fair hearing, and instructions for doing
                      so.
                  e. The circumstances under which expedited resolution can be requested, and
                      instructions for doing so.
                  f. An explanation that the consumer may represent himself/herself or use legal
                      counsel, a relative, a friend, or other spokesperson.
            3.    Advanced Notice must also explain:
                  a. The circumstances under which services will be continued pending resolution of
                      an appeal.
                  b. How to request that benefits be continued.
                  c. The circumstances under which the consumer may be required to pay the cost of
                      these services.
            4.    Exceptions to the Advanced Notice Rule. CMHCM may mail an adequate notice of
                  action, not later than the date of action to terminate, suspend or reduce previously
                  authorized services, if:
                  a. CMHCM receives a clear written statement signed by the consumer or his/her
                      legal representation that:
                      1. He/she no longer wishes services.
                      2. Gives information that requires termination or reduction of services and
                           indicates that he/she understands that this must be the result of supplying
                           that information.
                  b. The beneficiary has been admitted to an institution where he/she is ineligible
                      under Medicaid for further services.
                  c. The consumer's whereabouts are unknown and the post office returns CMHCM
                      mail directed to him/her indicating no forwarding address.
                  d. CMHCM establishes the fact that the beneficiary has been accepted for Medicaid
                      services by another local jurisdiction, State, territory, or commonwealth.
                  e. A change in the level of medical care is prescribed by the consumer's physician.
                  f. The date of the action will occur in less than 10 calendar days.
                  g. CMHCM has factual information confirming the death of the consumer.
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                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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            5.    Summary of Notice Requirements:
                   ACTION                     TYPE OF NOTICE        TIME FRAME OF NOTICE
                   Denial of service request  Adequate              At the time of decision
                   Person-Centered Plan       Adequate              At the time of plan development
                   Developed
                   Increase in Benefits       Adequate              At time of action
                   Reduction, suspension,     Advance               12 days before action
                   or termination of service
                   currently being received
                   Standard authorization     Adequate              Within 14 days of request
                   decision that denies or
                   limits services requested
                   Expedited authorization    Adequate              Within 3 working days of
                   decision that denies or                          request
                   limits services requested
                   Failure to provide         Adequate              At the time of action
                   services within 14
                   calendar days of the start
                   date agreed upon during
                   the person-centered
                   planning process and as
                   authorized by CMHCM
                                                                                                th
                   Delayed authorization      Adequate              Must be provided on the 14
                                                                                    rd
                   decision for which an                            day (or on the 3 working day
                   extension has not been                           for an expedited authorization
                   agreed to

       C.   CONTINUATION OR REINSTATEMENT OF SERVICES
            1.  CMHCM must continue services previously authorized while the local level
                appeal and/or State fair hearing are pending if:
                a. The consumer specifically requests to have the services continued, and
                b. The consumer or provider files the appeal timely; and
                c. The appeal involves the termination, suspension, or reduction of a previously
                    authorized course of treatment, and
                d. The services were ordered by an authorized provider, and
                e. The original period covered by the original authorization has not expired.
            2.  When services are continued or reinstated while the appeal is pending, the services
                must be continued until one of the following occurs:
                a. The consumer withdraws the appeal.
                b. Twelve calendar days pass after the notice of disposition providing the
                    resolution of the appeal against the consumer is mailed, unless the beneficiary,
                    within the 12-day timeframe, has requested a State fair hearing with
                    continuation of services until a State fair hearing decision is reached.
                c. A State fair hearing office issues a hearing decision adverse to the beneficiary.
                d. The time period or service limits of the previously authorized service has been
                    met.
            3.  If CMHCM, or the State fair hearing administrative law judge reverses a decision to
                deny authorization of services, and the consumer received the disputed services
                while the appeal was pending, CMHCM or the State must pay for those services in
                accordance with State policy and regulations.
            4.  If CMHCM, or the State fair hearing administrative law judge reverses a decision to
                deny, limit, or delay services that were not furnished while the appeal was pending,
                CMHCM must authorize or provide the disputed services promptly, and as
                expeditiously as the consumer's health condition requires.


       D.   LOCAL APPEALS PROCESS (Appendix B, C and D)
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                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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            1.    The appeals process is initiated by an “action’ and consumers or their
                  representatives may also (or instead) file a Local Appeal, under the following
                  conditions:
                  a. It has been no more than 45 calendar days from the date of the notice of action.
                  b. Oral inquiries seeking to appeal an action will be treated as appeals in order to
                      establish the earliest possible filing date. The oral request for a local appeal is
                      confirmed in writing, unless an expedited resolution has been requested.
                  c. When the consumer, or representative, requests a local appeal not more than 12
                      calendar days from the date of the notice of action, CMHCM shall reinstate the
                      Medicaid services until disposition of the hearing with consumer approval.
            2.    When a consumer requests a local appeal, designated CMHCM staff will:
                  a. Give consumers reasonable assistance to complete forms and take other
                      procedural steps including, but not limited to translation and literacy support. This
                      includes but is not limited to providing interpreter services and toll free numbers
                      that have adequate TTY/TTD and interpreter capability.
                  b. Provide written acknowledgement that an appeal has been received.
                  c. Enter the appeal into the database to maintain a log of all requests.
                  d. Provide for an expedited review process:
                      1. Consumers may request an expedited appeal, (or provider making or
                           supporting consumer’s request) indicating that taking the time for a standard
                           resolution could seriously jeopardize the consumer’s life or health, or ability
                           to attain, maintain, or regain maximum function.
                      2. If a consumer requests an expedited appeal, a psychiatrist or licensed
                           psychologist will make the determination whether to expedite the appeal or
                           not. If the consumer’s provider makes the request, or supports the
                           consumer’s request, the expedited appeal will be granted.
                  e. Select an independent reviewer to review the appeal.
                  f. Ensure that the individual(s) who make the decisions on appeal are health care
                      professionals with appropriate clinical expertise when the denial is based on lack
                      of medical necessity or involves other clinical issues..
                  g. Provide the consumer with:
                      1. Reasonable opportunity to present evidence and allegations of fact or law in
                           person as well as in writing;
                      2. Opportunity, before and during the appeals process, to examine the
                           consumer’s case file, including medical records and any other documents or
                           records considered during the appeals process;
                      3. Opportunity to include, as parties to the appeal, the consumer and his or her
                           representative or the legal representative of a deceased consumer’s estate;
                      4. Information regarding the right to a fair hearing and the process to be used to
                           request the hearing.
                  h. Independent reviewer documents the decision and sends to Customer Service
                      Coordinator/designee with a copy to the Deputy Director of Services within the
                      required time frame.
                  i. Customer Service Coordinator/designee will log results of appeal into the
                      database.
            3.    Notice of Disposition Requirements:
                  a. The Customer Service Coordinator/designee shall provide written notice of the
                      disposition of the appeal, and will make reasonable efforts to provide oral notice
                      of an expedited resolution.
                  b. The content of a notice of disposition must include an explanation of the results
                      and the date it was completed.
                  c. When the appeal is not resolved in favor of a beneficiary, the notice of disposition
                      must also include:


                      1. The right to request a state fair hearing, and how to do so;
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                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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                       2. The right to request to receive benefits while the state fair hearing is pending,
                            if requested within 12 days of CMHCM mailing the notice of disposition, and
                            how to make the request; and
                       3. That the beneficiary may be held liable for the cost of those benefits if the
                            hearing decision upholds CMHCM’s action.
             4.    Notice of Disposition Timeframes:
                   a. Standard Resolution: CMHCM shall provide written notice of the disposition of
                       the appeal to the consumer within 45 calendar days from the date the appeal
                       was received. In the event the consumer requests an extension, or if CMHCM
                       satisfies State requirements for an extension, the notice of disposition timeframe
                       may be extended by up to 14 calendar days.
                   b. Expedited Resolution: In the event of an expedited appeal, CMHCM shall provide
                       notice of disposition no longer than 3 working days after the request for appeal
                       was received. If the request for an expedited appeal is denied, CMHCM shall:
                       1. Transfer the appeal to the timeframe for standard resolution or no longer
                            than 45 days from the date the appeal was filed.
                       2. Make reasonable efforts must be made to provide the consumer prompt oral
                            notice of the denial,
                       3. Give the consumer follow up written notice within 2 calendar days.
                       4. Inform consumers of their right to file a grievance if an expedited appeal is
                            denied.
                   c. Consumers have the right to appeal to the state level for CMHCM’s failure to act
                       within the above notice of disposition timeframes.

       E.    STATE FAIR HEARING APPEAL PROCESS (Appendix E)
             1.  A beneficiary has the right to request a state fair hearing when CMHCM takes an
                 “action”, or a grievance request is not acted upon within 60 calendar days. The
                 beneficiary does not have to exhaust local appeals before he or she can request a
                 fair hearing.
             2.  CMHCM shall issue a written notice of action to the affected beneficiary.
             3.  CMHCM may not limit or interfere with the beneficiary’s freedom to make a request
                 for a fair hearing.
             4.  Beneficiaries will be given 90 calendar days from the date of the notice to file a
                 request for a hearing.
             5.  If the beneficiary or representative requests a fair hearing not more than 12 calendar
                 days from the date of the notice of action, CMHCM shall reinstate the Medicaid
                 services until disposition of the hearing by the administrative law judge.
             6.  If the beneficiary’s services were reduced, terminated or suspended without advance
                 notice, CMHCM shall reinstate services to the level before the action.
             7.  The parties to the state fair hearing include the PIHP, the beneficiary and his or her
                 representative, or the representative of a deceased beneficiary’s estate.
             8.  Expedited hearings are available.

       F. LOCAL GRIEVANCE PROCESS (Appendix F and G)
          1. A consumer, guardian, or parent of a minor child or his/her legal representative may
             request to file a grievance, verbally or in writing, at any time. When a request is made to
             file a grievance, the Customer Service Coordinator/designee will:
             a. Give consumers reasonable assistance to complete forms and take other procedural
                  steps. This includes but is not limited to providing interpreter services and toll free
                  numbers that have adequate TTY/TTD and interpreter capability.
             b. Determine whether the grievance is more appropriately a recipient rights complaint,
                  and if so, refers the complaint, with the beneficiary’s permission, to the Office of
                  Recipient Rights.
             c. Provide written acknowledgement that a grievance has been received.
             d. Log the grievance for reporting to CMHCM’s Quality Improvement Program.
             e. Provide for an expedited review process:
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                                             SERVICES ADMINISTRATION – CHAPTER 2
            CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
               RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
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                 1. Consumers may request an expedited grievance, (or provider making or
                     supporting consumer’s request) indicating that taking the time for a normal
                     grievance process could seriously jeopardize the consumer’s life or health, or
                     ability to attain, maintain, or regain maximum function.
                 2. The Deputy Director of Services/designee will determine if a grievance is to be
                     expedited.
                 3. If the expedition of the grievance is denied it will follow the regular grievance
                     process.
              f. Submit the written grievance to an independent reviewer and a Deputy
                 Director/designee with the authority to require corrective action.
              g. Ensure that the individual(s) who make the decisions on the grievance are health
                 care professionals with appropriate clinical expertise in treating the consumer’s
                 condition or disease if the grievance:
                 1. Involves clinical issues or
                 2. Involves the denial of an expedited resolution of an appeal (of an action).
              h. Facilitate resolution of the grievance as expeditiously as the consumer’s health
                 condition requires, but no later than 60 calendar days of receipt of the grievance.
              i. Provide the Medicaid beneficiary a written notice of disposition not to exceed 60
                 calendar days from the day CMHCM received the grievance. The content of the
                 Notice of disposition must include:
                 1. The results of the grievance process
                 2. The date the grievance process was concluded
                 3. The beneficiary's right to request a state fair hearing and/or file a local appeal if
                     the notice of disposition is more than 60 days from the date of the request for a
                     grievance and how to access the local appeal and/or state fair hearing process.
              j. Customer Service Coordinator/designee will log results of grievance into the
                 database.

       G.   MDCH ALTERNATIVE DISPUTE RESOLUTION (Appendix H)
            1. If a non-Medicaid consumer is dissatisfied with the Local Appeal Process resolution,
               they can pursue a resolution through the MDCH Alternative Dispute Resolution
               Process within ten business days of receipt of the decision of Local Appeal Process or
               upon CMHCM’s failure to meet standard or expedited appeal notice of disposition
               timeframes.
                  a. Access to the MDCH process does not require agreement by both parties, but
                      may be initiated solely by the consumer.
                  b. The individual has ten business days from the written notice of the CMHCM
                      dispute resolution process outcome to request access to the MDCH Alternative
                      Dispute Resolution Process.
                  c. CMHCM shall also offer to assist the individual in filing a dispute with MDCH.
                  d. MDCH will accept a written request for a review, however, the request must
                      include the following information and CMHCM shall also include the items listed
                      here in communications with MDCH.
                      1. Name of the CMHCM recipient/applicant.
                      2. Name of guardian legally empowered to make treatment decisions, or parent
                           or a minor.
                      3. Daytime telephone number where the recipient/applicant, guardian legally
                           empowered to make treatment decisions or parent of a minor child may be
                           reached.
                      4. Name of community mental health agency where services were denied, etc.
                      5. Description of the adverse impact on the recipient/applicant caused by the
                           denial, suspension, reduction, or termination of services.



                 e.   Written requests should be directed to:
                          Michigan Department of Community Health
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                                 SERVICES ADMINISTRATION – CHAPTER 2
                CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                   RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                          Page 11 of 19


                               Division of Program Development, Consultation and Contracts
                               Bureau of Community Mental Health Services
                               ATTN: Request for CDH Level Dispute Resolution
                                                       th
                               Lewis Cass Building – 6 Floor
                               Lansing, MI 48913
                       f. MDCH shall review all requests within two business days of receipt.
                       g. In the event that the MDCH representative believes that the denial, suspension,
                          termination or reduction of services and/or supports will pose an immediate and
                          adverse impact upon the individual's health and/or safety, the issue will be
                          referred within 1 business day to the Bureau of Community Mental Health
                          Services for contractual action with applicable provisions of the MDCH/CMHSP
                          contract.
                       h. In all other cases, the MDCH representative will complete its review of the
                          dispute within 15 business days. Written notice of the resolution shall be
                          submitted to the consumer, his/her guardian or parent of a minor consumer.


Policy Approved: 1/30/07
Revised: 3/31/09
Revised: 5/14/09
Revised: 2/22/11
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 12 of 19


Appendix A – Notice of Action
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 13 of 19


Appendix B
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 14 of 19


Appendix C
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 15 of 19


Appendix D
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 16 of 19


Appendix E
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 17 of 19


Appendix F
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 18 of 19


Appendix G
COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN
                                              SERVICES ADMINISTRATION – CHAPTER 2
             CONCERNS, COMPLAINTS, DISPUTES, GRIEVANCES, AND APPEALS – SECTION 100
                RECIPIENT DISPUTE RESOLUTION AND GRIEVANCE SYSTEMS – SUBJECT 002
                                                                       Page 19 of 19


Appendix H

				
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