THE COMMUNITY MENTAL HEALTH FOR
CENTRAL MICHIGAN
CONSUMER GRIEVANCE SYSTEM
The grievance system includes:



A local appeal process for an appeal of an
“action”
A state level fair hearing process for an
appeal of an “action”
A local grievance process for expressions of
dissatisfaction about any matter other than
those that meet the definition of an
“action”
ACTION
An action is a decision that adversely
impacts a Medicaid beneficiaries claim for
services due to:
Denial or limited authorization of a
requested service
Reduction, suspension or termination of
a previously authorized service
Notice of actions:
1.
2.
Adequate Notice of Action
Advance Notice of Action
Adequate Notice of Action


Written statement advising the
beneficiary of a decision to deny or limit
authorization of Medicaid services
requested.
Notice is provided to the Medicaid
beneficiary on the same date the action
takes effect, or at the time of the
signing of the individual plan of service
Adequate notice must contain:





A statement of what action is being taken
The reasons for the intended action
The specific regulations that support the
action
Explanation of the individual’s right to request
a fair hearing and instructions for doing so
An explanation that the beneficiary may
represent himself/herself or use legal counsel,
a relative or friend
Advance Notice of Action


Written statement advising the
beneficiary of a decision to reduce,
suspend or terminate Medicaid services
currently provided
Notice must be provided/mailed to the
Medicaid beneficiary at least 12
calendar days prior to the proposed
date the action is to take effect
Advance notice must also contain:



The circumstances under which services
will be continued pending resolution of
the appeal
How to request that benefits be
continued
The circumstances under which the
beneficiary may be required to pay the
costs of these services
State Fair Hearing Appeal Process


Beneficiaries have 90 calendar days
from the date of the written notice of
action to request a hearing
If the beneficiary requests a fair hearing
within 12 calendar days from the date
of the notice of action, services must be
reinstated until disposition of the
hearing
State Fair Hearing (cont.)


The parties to the state fair hearing
include CMHCM, the beneficiary and
state level administrative law judge
The administrative law judge’s decision
and order is the final determination of
the department
Local Appeal Process


The beneficiary has 45 calendar days
from the date of notice of action to
request a local appeal
If the beneficiary requests a local
appeal within 12 calendar days from the
date of the notice of action services
must be reinstated until disposition of
the hearing
Local Appeals (cont.)


CMHCM will use the CMHCM Office of
Recipient Rights system as the primary
local appeal system; however, informal
resolution of concerns may first occur
with agency supervisors
The dispute or grievance can be
presented in person, on the telephone
or in writing
Local Appeals (cont.)

CMHCM must resolve the appeal and
provide notice of disposition to the
beneficiary within 45 days from the day
CMHCM receives the appeal
Expedited Appeals


A beneficiary or their provider can
request an expedited review when the
time for the normal appeal review
process could jeopardize the
beneficiary's life, health or ability to
maintain functioning
An expedited hearing is held within 3
workdays after receipt of the hearing
request
Grievance

Recipient’s expression of dissatisfaction
about 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 recipient’s.
CMHCM Local Grievance Procedure

CMHCM will use the CMHCM Office of
Recipient Rights system as the primary
local dispute resolution and grievance
systems; however, informal resolution of
concerns may first occur with agency
supervisors.
CMHCM Local Grievance Procedure
(cont.)


The dispute or grievance can be
presented in person, on the telephone
or in writing
CMHCM will provide the beneficiary
written notification of disposition within
60 days from the day the
grievance/complaint is received
Questions?