Page 1 of 11 SECTION: Contracts/Network180 SUBJECT: Appeals and Grievances DATE OF ORIGIN: 6/1/98 REVIEW DATES: 2/17/99, 4/1/99, 10/1/99, 5/1/00, 1/1/02, 6/1/02, 10/1/03, 8/1/04, 3/1/05, 10/1/05, 1/1/06, 1/1/07, 5/1/08, 9/14/10, 10/1/13, 2/19/14, 11/14/14, 4/19/16, 3/24/17 EFFECTIVE DATE: 1/2/18 APPROVED BY: EXECUTIVE DIRECTOR I. PURPOSE: To have established appeal and grievance procedures to address decisions made that impact an individual s access to or satisfaction with services and supports. II. REFERENCES/LEGAL AUTHORITY: Balanced Budget Act of 1997, PL 105-33 42 C.F.R. 431.200 et seq. 42 C.F.R. 438.400 et seq. Michigan Mental Health Code, 1974 PA 258, MCL 330.1772 et seq. Michigan Department of Health and Human Services, Grievance and Appeal Technical Requirement, PIHP Grievance System for Medicaid Beneficiaries (January 2016), Medicaid Managed Specialty Supports and Services Contract Attachment P 6.3.1.1 Michigan Department of Health and Human Services, CMHSP Local Dispute Resolution Process, CMHSP Managed Mental Health Supports and Services Contract Attachment C 6.3.2.1 Michigan Administrative Hearing System for the Department of Health and Human Services, Administrative Hearing Pamphlet (2015) III. DEFINITIONS: A. Action or Adverse Benefit Determination A decision that adversely impacts an individual s claim for services due to: 1. Denial or limited authorization of a requested service, including the type or level of service. 2. Reduction, suspension or termination of a previously authorized service. 3. Denial, in whole or in part, of payment for a service. 4. 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.
Page 2 of 11 5. Failure to make an expedited authorization decision within three (3) working days from the date of receipt of a request for expedited service authorization. 6. Failure to provide services within 14 calendar days of the start date agreed upon during the person-centered/individualized service planning process and as authorized by Network180 or its providers. 7. Failure to act within 30 calendar days from the date of a request for a standard appeal. 8. Failure to act within 72 hours from the date of a request for an expedited appeal. 9. Failure to provide notice and disposition of a grievance within 90 calendar days from the date the grievance was received. B. Additional Mental Health Services Supports and services available to Medicaid 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 of Action/Adverse Benefit Determination Written statement advising the individual of a decision to deny or limit authorization of services requested. Notice is provided to the individual on the same date the action takes effect, or at the time of the signing of the individual plan of services/supports. D. Advance Notice of Action/Adverse Benefit Determination Written statement advising the individual of a decision to reduce, suspend, or terminate services currently provided. Notice must be provided/mailed to Medicaid beneficiaries at least 12 calendar days prior to the proposed date the Adverse Benefit Determination is to take effect. Individuals who do not have or are not eligible for Medicaid must be provided/mailed notice at least 30 calendar days prior to the proposed date the Adverse Benefit Determination is to take effect. E. Appeal Request for a review of an Adverse Benefit Determination, as defined above. F. Authorization of Services The processing of requests for initial and continuing service delivery. G. Beneficiary An individual who has been determined eligible for Medicaid and who is receiving or may qualify to receive Medicaid services. H. Expedited Appeal The expeditious review of an action, requested by an individual or the individual s provider, when the time necessary for the normal appeal review process could seriously jeopardize the individual s life or health, or ability to attain, maintain or regain maximum function. If the individual requests the expedited review, the PIHP determines if the request is warranted. If the individual s provider makes the request, or supports the individual s request, the PIHP must grant the request.
Page 3 of 11 I. Fair Hearing Impartial state level review of a Medicaid beneficiary s appeal of an action presided over by a Michigan Department of Health and Human Services (MDHHS) Administrative Law Judge. Also referred to as Administrative Hearing. J. Grievance An individual s expression of dissatisfaction about Network180 or provider service issues, other than an Adverse Benefit Determination. Grievances may include, but are not limited to, quality of care or services provided and aspects of interpersonal relationships between a service provider and the individual. K. Grievance Process Impartial local level review of a grievance (expression of dissatisfaction) about service issues other than an Adverse Benefit Determination. L. Grievance System Federal terminology for the overall local system of grievance and appeals required for Medicaid beneficiaries in the managed care context, including access to the state fair hearing process. M. Local Appeal Process Impartial local level PIHP review of an individual s appeal of an action presided over by individuals not involved with decision-making or previous level of review. N. Michigan Administrative Hearing System (MAHS) Independent agency within the Michigan Department of Licensing and Regulatory Affairs that hears contested matters for agencies within state government. O. 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. P. Notice of Disposition Written statement of the decision for each local appeal and/or grievance provided to an individual. Q. Recipient Rights Complaint Written or verbal statement by an individual served, or anyone acting on behalf of the individual, alleging a violation of a Michigan Mental Health Code protected right cited in Chapter 7, which is resolved through the processes established in Chapter 7A. IV. GRIEVANCE AND APPEAL SYSTEM REQUIREMENTS: A. Federal regulations (42 CFR 438.28) requires the state to ensure through its contracts with PIHPs that each PIHP has an overall grievance and appeal system in place for Medicaid beneficiaries that complies with Subpart F of Part 438. The grievance system must provide Medicaid beneficiaries: 1. A local PIHP appeal process for challenging an Adverse Benefit Determination made by Network180 or one of its providers. 2. Access to the state level fair hearing process for an appeal of an Adverse Benefit
Page 4 of 11 Determination. 3. A local PIHP grievance process for expression of dissatisfaction about any matter other than those that meet the definition of an Adverse Benefit Determination. 4. The right to concurrently file an appeal of an Adverse Benefit Determination and file a PIHP grievance regarding other service complaints. 5. The right to request a hearing after exhausting the PIHP appeal of an Adverse Benefit Determination. 6. The right to request, and have, Medicaid benefits continued while a local PIHP appeal and/or state fair hearing is pending. 7. The right to have a provider, acting on the beneficiary s behalf and with the beneficiary s written consent, file an appeal to the PIHP. The provider may file a grievance or request for a state fair hearing on behalf of the beneficiary only if the state permits the provider to act as the beneficiary s authorized representative in doing so. Punitive action may not be taken by the PIHP against a provider who acts on the beneficiary s behalf with the beneficiary s written consent to do so. V. SERVICE AUTHORIZATION DECISIONS: A. When a Medicaid service authorization is processed (initial request or continuation of service delivery), Network180 or its providers must provide the beneficiary written service authorization decision within the specified timeframes and as expeditiously as the beneficiary s health condition requires. The service authorization must meet the requirements for either standard authorization or expedited authorization: 1. Standard Authorization Notice of the authorization decision must be provided as expeditiously as the beneficiary s health condition requires, and no later than 14 calendar days following receipt of a request for service. a. If the beneficiary or provider requests an extension OR if Network180 justifies (to the state agency upon request) a need for additional information and how the extension is in the beneficiary s interest, Network180 may extend the 14- calendar day time period up to 14 additional calendar days. 2. Expedited Authorization In cases where a provider indicates, or Network180 determines, that following the standard timeframe could seriously jeopardize the beneficiary s life or health or ability to attain, maintain or regain maximum function, Network180 or the provider must make an expedited authorization decision and provide notice of the decision as expeditiously as the beneficiary s health condition requires, and no later than 72 hours after receipt of the request for service. a. If the beneficiary requests an extension, or if Network180 justifies (to the state agency upon request) a need for additional information and how the extension is in the beneficiary s interest, Network180 may extend the 72-hour time period by up to 14 calendar days. B. When a standard or expedited authorization of services decision is extended, Network180 or its providers must give the beneficiary written notice of the reason for the decision to extend the timeframe, and inform the beneficiary of the right to file an
Page 5 of 11 appeal if he or she disagrees with that decision. Network180 or its providers must issue and carry out its determination as expeditiously as the beneficiary s health condition requires and no later than the date the extension expires. VI. NOTICE OF ACTION/ADVERSE BENEFIT DETERMINATION: A. A Notice of Action/Adverse Benefit Determination and Local Appeal Request Form must be provided to an individual whenever an authorization decision constitutes an Action (hereafter referred to as Adverse Benefit Determination) including when a request for service(s) is denied due to lack of eligibility or medical necessity; the amount, duration or scope of an authorized service is less than requested or less than currently authorized; the service authorization is not made timely; or a previously authorized service is terminated. In these situations, Network180 or its providers must provide a Notice of Action/Adverse Benefit Determination that informs the individual of the basis for the action that Network180 or its providers have taken, or intend to take, and the processes available to appeal the decision. For Medicaid beneficiaries, Request for Hearing Forms will be provided after the local appeal process is exhausted. B. The notice must be in writing and meet language format needs of the individual to understand the content (i.e., the format meets the needs of those with limited English proficiency and/or limited reading proficiency). C. Notice must be given whenever an Adverse Benefit Determination is made, even if the individual does not specifically request notice or appeal information. In addition, even when the individual has agreed to a different service from what was requested, he or she must still receive adequate notice. This is to guard against any undue influence over vulnerable persons who might, in some circumstances, be afraid to disagree with staff recommendations, and allows the individual the option to request an appeal at a later time. D. The requesting provider, in addition to the individual, must be provided of any decision by Network180 to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested. Notice to the provider is not required to be in writing. E. 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 adequate or advance written notice. 1. Adequate Notice is a written notice provided to the individual at the time of EACH Adverse Benefit Determination. The Individual Plan of Service (IPOS), developed through a person-centered planning process and finalized with the individual, must include, or have attached the adequate notice provisions. 2. Advance Notice is written notice required when an Adverse Benefit Determination
Page 6 of 11 is being taken to reduce, suspend or terminate services an individual is currently receiving. For Medicaid beneficiaries, advance notice must be provided/mailed 12 calendar days before the intended Adverse Benefit Determination takes effect. Individuals who do not have or not eligible for Medicaid must be provided/mailed advance notice at least 30 calendar days before the intended Adverse Benefit Determination takes effect. F. The content of both adequate and advance notices must include an explanation of: 1. What action Network180 or a provider intends to take, 2. The reason(s) for the action, 3. An explanation that 42 CFR 440.230(d) is the basic legal authority for an action to place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures, 4. The individual s right to file a local appeal, and instructions for doing so, 5. A Medicaid beneficiary s right to request a hearing, and instructions for doing so, 6. The circumstances under which expedited resolution can be requested, and instructions for doing so, 7. An explanation that the individual may represent himself or use legal counsel, a relative, a friend or other spokesman. 8. The individual has the right to receive copies, free of charge, of all records and information relevant to the individual s claim for benefits. G. The content of an advance notice to a Medicaid beneficiary must also include an explanation of: 1. The circumstances under which services will be continued pending resolution of the appeal, 2. How to request that benefits be continued, and 3. The circumstances under which the beneficiary may be required to pay the costs of these services. H. There are limited exceptions to the advance notice requirement. Network180 or its providers may provide/mail adequate notice not later than the date of action to terminate, suspend or reduce previously authorized services if: 1. There is factual information confirming the death of the individual. 2. Network180 or its providers receives a clear written statement signed by the individual that he/she no longer wishes services, or 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. 3. The individual has been admitted to an institution where he/she is ineligible under Medicaid for further services. 4. The individual s whereabouts are unknown and the post office returns mail directed to him/her indicating no forwarding address. 5. Network180 or its providers establishes the fact that the individual has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth.
Page 7 of 11 6. A change in the level of medical care is prescribed by the individual s physician. 7. The date of the Adverse Benefit Determination will occur in less than 10 calendar days. VII. MEDICAID SERVICES CONTINUATION OR REINSTATEMENT: A. Network180 or its providers must continue Medicaid services previously authorized while the local PIHP appeal and/or state fair hearing are pending if: 1. The beneficiary specifically requests to have the services continued timely (on or before the latter of 10 calendar days from the date of the notice, or the intended effective date of the proposed Adverse Benefit Determination), and 2. The beneficiary or provider files the appeal timely, and 3. The appeal involves the termination, suspension or reduction of a previously authorized course of treatment, and 4. The services were ordered by an authorized provider, and 5. The original period covered by the original authorization has not expired, or B. When the Medicaid beneficiary s services are continued or reinstated while the appeal is pending, the services must be continued until one of the following occurs: 1. The beneficiary withdraws the appeal. 2. 10 calendar days pass after the PIHP mails the notice of disposition providing the resolution of the appeal against the beneficiary, unless the beneficiary, within the 10-day timeframe, has requested a State fair hearing with continuation of services until a State fair hearing decision is reached. 3. A State fair hearing office issues a hearing decision adverse to the beneficiary. 4. The time period or service limits of the previously authorized service has been met. C. If the PIHP, or the MDHHS fair hearing administrative law judge reverses a decision to deny authorization of services, and the beneficiary received the disputed services while the appeal was pending, the PIHP or the State must pay for those services in accordance with State policy and regulations. D. If the PIHP, or the MDHHS fair hearing administrative law judge reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the PIHP must authorize or provide the disputed services promptly, and as expeditiously as the beneficiary s health condition requires, but not more than 72 hours from the date it receives notice reversing the determination. VIII. STATE FAIR HEARING PROCESS FOR MEDICAID BENEFICIARIES: A. Federal regulations provide a Medicaid beneficiary the right to an impartial review by a Michigan Administrative Hearing System (MAHS) administrative law judge (ALJ), of an action taken by Network180 or its providers. 1. A Medicaid beneficiary has the right to request a fair hearing when Network180 or its providers make an Adverse Benefit Determination or a grievance request is not
Page 8 of 11 acted upon within 90 calendar days. The beneficiary must exhaust the local appeal option before he/she can request a fair hearing. 2. A written Notice of Action/Adverse Benefit Determination must be issued to the affected beneficiary. 3. Network180 or its providers may not limit or interfere with the beneficiary s freedom to make a request for a fair hearing. 4. Beneficiaries are given 90 calendar days from the date of the notice to file a request for a fair hearing. 5. If the beneficiary, or representative, requests a fair hearing not more than 12 calendar days from the date of notice, Medicaid services must be reinstated until disposition of the hearing by the ALJ. 6. If the beneficiary s services were reduced, terminated or suspended without advance notice, services must be reinstated to the level before the action. 7. The parties to the state fair hearing include the PIHP, Network180 or the provider, if applicable, the beneficiary and his or her representative, or the representative of a deceased beneficiary s estate. A Recipient Rights Officer shall not be appointed as Hearing Officer due to the inherent conflict of roles and responsibilities. 8. Expedited hearings are available. IX. LOCAL APPEAL PROCESS: A. Federal and State regulations provide individuals the right to a local level appeal of an Adverse Benefit Determination. An individual may request a local appeal under the following conditions: 1. Medicaid beneficiaries have 60 calendar days from the date of notice to request a local appeal. 2. Individuals who do not have or who are not eligible for Medicaid have 30 calendar days from the date of the notice to request a local appeal. Appeals requested by individuals who do not have or are not eligible for Medicaid are reviewed on a caseby-case basis and are not subject to the requirement to continue services while the appeal is pending. 3. An oral request for a local appeal of an Adverse Benefit Determination is treated as an appeal to establish the earliest possible filing date for appeal. The oral request must be confirmed in writing unless the beneficiary requests expedited resolution. 4. The individual shall file the appeal with the organizational unit approved and administratively responsible for facilitating local appeals. 5. If a Medicaid beneficiary, or representative, requests a local appeal not more than 10 calendar days from the date of the notice, Medicaid services must be reinstated until disposition of the hearing. B. When an individual requests a local appeal, the PIHP is required to: 1. Give individuals reasonable assistance to complete forms and to take other procedural steps. This includes but is not limited to providing interpreter services and toll-free numbers that have adequate TTY/TDD and interpreter capability. 2. Acknowledge receipt of each appeal.
Page 9 of 11 3. Maintain a log of all requests for appeal to allow reporting to the PIHP Quality Improvement Program. 4. Ensure that the individual(s) who make the decisions on the appeal were not involved in the previous level review or decision-making. 5. Ensure that the individual(s) who make the decisions on the appeal are health care professionals with appropriate clinical expertise in treating the individual s condition or disease when the appeal is of a denial based on lack of medical necessity or involves other clinical issues. 6. Provide the individual or representative with: a. Reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing; b. Opportunity, before and during the appeals process, to examine the file, including medical records and any other documents considered during the appeal process; c. Opportunity to include as parties to the appeal, the individual and his or her representative or the legal representative of a deceased beneficiary s estate; d. Information regarding the right to a fair hearing and the process to be used to request the hearing, if the individual is a Medicaid beneficiary. C. Notice of Disposition Timeframes 1. The PIHP must provide written notice of the disposition of the appeal, and must also make reasonable efforts to provide oral notice of an expedited resolution. a. Standard Resolution: The PIHP must resolve the appeal and provide notice of the disposition to the affected parties as expeditiously as the individual s health condition requires, but not to exceed 30 calendar days from the day the PIHP receives the appeal, and not exceeding 15 business days for individuals who do not have or are not eligible for Medicaid. b. Expedited Resolution: An expedited resolution is required when the PIHP determines (for a request from the individual) or the provider indicates (in making the request on behalf of, or in support of the individual s request) that taking the time for a standard resolution could seriously jeopardize the individual s life, health or ability to attain, maintain or regain maximum function. For Medicaid beneficiaries, the PIHP must resolve the appeal and provide notice of disposition to the affected parties no longer than 72 hours after the PIHP receives the request for expedited resolution of the appeal. For individuals who do not have or who are not eligible for Medicaid, the review shall be completed within 24 hours of receipt of all necessary information by relevant staff involved in the local appeal process. 2. The PIHP may extend the notice of disposition timeframe by up to 14 calendar days if the individual requests an extension, or if the PIHP shows to the satisfaction of the state that there is a need for additional information and how the delay is in the individual s interest. 3. If the PIHP denies a request for expedited resolution of an appeal, it must: a. Transfer the appeal to the timeframe for standard resolution; b. Make reasonable efforts to give the individual prompt oral notice of the denial
Page 10 of 11 of expedited resolution, and c. Give the individual follow up written notice within 2 calendar days. D. Notice of Disposition Requirements 1. The content of the notice of disposition must include an explanation of the results of the resolution and the date it was completed. 2. When the appeal is not resolved wholly in favor of a Medicaid beneficiary, the notice of disposition must also include information about: a. The right to request a State fair hearing, and how to do so; b. The right to request to receive benefits while the hearing is pending, if requested within 12 calendar days of the PIHP mailing the notice of disposition, and how to make the request; and c. A statement explaining that the beneficiary may be held liable for the cost of those benefits if the hearing decision upholds the action taken. 3. When the appeal is not resolved wholly in favor an individual who does not have or does not qualify for Medicaid, notice must also include information about: a. The individual s right to access the MDHHS Alternative Dispute Resolution (ADR) Process (the individual must have already gone through the local appeal process before accessing the ADR Process). The individual has 10 business days from the date of written notice of the disposition of the local appeal outcome to request access to the MDHHS ADR Process. Requests can be completed on the MDHHS ADR Request Form, or submitted in writing on any piece of paper; b. The individual s right to file a recipient rights complaint with the Recipient Rights Office alleging a violation of the individual s right to treatment suited to his/her condition, if the individual is a current recipient of Network180 services(s). X. LOCAL GRIEVANCE PROCESS: A. Federal and State regulations provide individuals the right to a local grievance process to express dissatisfaction about service issues that are not Adverse Benefit Determinations. A grievance may be filed at any time by the individual, guardian, parent of a minor child or an individual s authorized legal representative, either orally or in writing. All grievances shall be filed with the PIHP. B. For each grievance filed, the PIHP is required to: 1. Give the individual reasonable assistance to complete forms and to take other procedural steps. This includes but is not limited to providing interpreter services and toll-free numbers that have adequate TTY/TDD and interpreter capability. 2. Acknowledge receipt of the grievance; 3. Maintain a log of all grievances for reporting to the PIHP Quality Improvement Program; 4. Ensure that the individual(s) who make the decisions on the grievance are health care professionals with appropriate clinical expertise in treating the individual s
Page 11 of 11 condition or disease if the grievance involves clinical issues, none of whom shall have been involved in any previous level of review or decision making; 5. Submit the written grievance to the appropriate staff including a PIHP administrator with the authority to require corrective action, none of whom shall have been involved in the initial determination; 6. Provide the individual with written notice of disposition not to exceed 90 calendar days from the day the PIHP received the grievance. The content of the notice of disposition must include: a. The results of the grievance process, b. The date the grievance process was concluded, c. A Medicaid beneficiary s right to request a fair hearing if the notice of disposition is more than 90 days from the date of the request for a grievance, and d. How to access the fair hearing process. C. Providers shall continue to respond to and resolve individuals complaints and concerns. This is encouraged in order to address the individual s needs as quickly and efficiently as possible and to foster the individual/provider relationship. However, if an individual indicates he or she wants to file a grievance, he or she must be given information about the grievance process and directed to Network180 Customer Services or to the PIHP Customer Services. Contact information for the PIHP Customer Services can be found within the Lakeshore Region Guide to Services Handbook which is required to be offered at intake and annually at the time of the person-centered planning meeting. XI. RECIPIENT RIGHTS COMPLAINT PROCESS: Individuals have the right to file recipient rights complaints under the authority of the State Mental Health Code. Recipient Rights complaint requirements are articulated in the CMHSP Managed Mental Health Supports and Services contract, Attachment C 6.3.2.1 CMHSP Local Dispute Resolution Process. XII. ATTACHMENTS: A. Notice of Action/Adverse Benefit Determination B. Notice of Action/Adverse Benefit Determination (Spanish) C. Request for State Fair Hearing Form D. Hearing Withdrawal Form E. Local Appeal Request Form F. Local Appeal Request Form (Spanish)