Community Mental Health &
Substance Abuse Services
of St. Joseph County
Operating
Procedure
Subject: Second Opinions /Grievance & Appeals/Dispute Resolution
23.01
Grievance and Appeals
Application:
All Departments
Effective
01/01/14
Reviewed
Revised
Approved
PURPOSE
To outline the requirements and process for second opinions, grievance and appeal, and dispute
resolution.
DEFINITIONS
The Southwest Michigan Behavioral Health PIHP (herein after referred to as SWMBH/PIHP) is a formal
partnership consisting of eight Community Mental Health Services Programs (CMHSPs) formed in 2014
under MCL 124.1 of the Intergovernmental Contracts between Municipal Corporations Act (ICBMCA).
The four CMHSPs consist of Barry County Community Mental Health Authority, Berrien County
Community Mental Health Authority, Pines Behavioral Health (Branch County), Summit Pointe (Calhoun
County, Woodlands Behavioral Healthcare (Cass County), Kalamazoo Community Mental Health and
Substance Abuse Services and Community Mental Health, Substance Abuse Services of St. Joseph County
and Van Buren Community Mental Health Authority.
Action
Additional Mental Health Services
Adequate Notice of Action
Advance Notice of Action
Appeal
Authorization of Services
Beneficiary
Expedited Appeal
Fair Hearing
Grievance
Grievance Process
Grievance System
Local Appeal Process
Medicaid Beneficiary
Medicaid Services
Notice of Disposition
Recipient Rights Complaint
Rights
Second Opinion
POLICY
I.
The Due Process Clause of the U.S. Constitution guarantees that Medicaid beneficiaries
must receive "due process" whenever benefits are denied, reduced or terminated. Due
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Process includes: (1) prior written notice of the adverse action (2) a fair hearing before an
impartial decision maker (3) continued benefits pending a final decision and (4) a timely
decision, measured from the date the complaint is first made. Nothing about managed
care changes these due process requirements.
II.
Persons receiving mental health services who are Medicaid beneficiaries eligible for
Specialty Supports and Services have various avenues available to them to resolve
disagreements or complaints. There are three processes under authority of the Social
Security Act and its federal regulations that articulate federal requirements regarding
grievance and appeals for Medicaid beneficiaries who participate in managed care.
Grievance and appeal process requirements for Medicaid beneficiaries were significantly
expanded through federal regulations implementing the Balanced Budget Act (BBA) of
1997.
III.
Medicaid beneficiaries have rights and dispute resolution protections under federal
authority of the Social Security Act, including:
A.
State fair hearings through authority of 42 CFR 431.200 et seq.
B.
Local appeals through authority of 42 CFR 438.400 et seq.
C.
Local grievances through authority of 42 CFR 438.400 et seq.
IV.
Persons who do not have Medicaid are entitled to a local dispute resolution process which
must first be exhausted before accessing the MDCH Dispute Resolution Process.
V.
All persons receiving public mental health and substance abuse services also have rights
and dispute resolution protections under authority of the State of Michigan Mental Health
Code, (hereafter referred to as the "Code") Chapters 7, 7A, 4 and 4A, and Michigan’s
Public Act 368 including:
VI.
A.
Recipient Rights complaints through authority of the Mental Health Code (MCL
330.1772 et seq.)
B.
Medical Second Opinion through authority of the Mental Health Code (MCL
330.1705)
C.
Recipient Rights complaints through the authority of PA 368 as defined in the
Administrative Rules for Substance Abuse Service Programs in Michigan ®
325.14301 et seq
This policy will apply to both Medicaid and Non-Medicaid beneficiaries. While the
Southwest Michigan Behavioral Health (SWMBH) has overall responsibility for the
Medicaid local appeal and grievance process, KCMHSAS has delegated responsibility
for the MA local appeal process and for the grievance and appeals process for persons
receiving services who do not have Medicaid.
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GRIEVANCE SYSTEM GENERAL REQUIREMENTS
Federal regulation (42 CFR 438.228) requires the state to ensure through its contracts
with PIHPs/CMHSP’s, that each PIHP/CMHSP has an overall grievance system in place
for beneficiaries that complies with Subpart F of Part 438.
A.
The grievance system must provide Medicaid beneficiaries:
1.
A local CMHSAS-SJC and CSSN appeal process for challenging an
“action” taken by the , CSSN or o CMHSAS-SJC ne of its agents.
2.
A CMHSAS-SJC local appeals process for appeal of an action.
3.
Access to the state level fair hearing process for an appeal of an "action”.
4.
A local CMHSAS-SJC grievance process for expressions of dissatisfaction
about any matter other than those that meet the definition of an "action".
5.
The right to concurrently file a CMHSAS-SJC level appeal of an action,
and request a State fair hearing on an action, and file a CMHSAS-SJC
level grievance regarding other service complaints.
6.
The right to request a State fair hearing before exhausting the CMHSASSJC level appeal of an "action”.
7.
The right to request, and have, benefits continued while a local CMHSASSJC appeal and/or state fair hearing is pending.
8.
The right to have a provider, acting on the beneficiary's behalf and with
the beneficiary's written consent, file an appeal to the CMHSAS-SJC. 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.
B.
The grievance system must provide Non-Medicaid beneficiaries:
1.
A CMHSAS-SJC appeal process for challenging an "action" taken by
CMHSAS-SJC or one of its agents.
2.
Access to a local dispute resolution process.
3.
CMHSAS-SJC grievance process for expressions of dissatisfaction about
any matter other than those that meet the definition of an "action".
4.
The right to concurrently file a CMHSAS-SJC level appeal of an action,
and file a CMHSAS-SJC level grievance regarding other service
complaints and file a complaint with the CMHSAS-SJC Office of
Recipient Rights.
5.
The right to a MDCH level dispute resolution process after the local
appeal/dispute resolution process has been exhausted.
6.
The right to request, and have, benefits continued while a CMHSAS-SJC
or MDCH Dispute Resolution appeal is pending.
VIII.
A.
SERVICE AUTHORIZATION DECISIONS
When a service authorization is processed (initial request or continuation of
service delivery) the CMHSAS-SJC must provide the beneficiary written service
authorization decision within specified timeframes and as expeditiously as the
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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 the
CMHSAS-SJC justifies (to the state agency upon request) a need
for additional information and how the extension is in the
beneficiary's interest; the CMHSAS-SJC 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 CMHSAS-SJC determines, that
following the standard timeframe could seriously jeopardize the
beneficiary's life or health or ability to attain, maintain or regain maximum
function, CMHSAS-SJC 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 three (3) working days after
receipt of the request for service.
a.
If the beneficiary requests an extension, or if CMHSAS-SJC
justifies (to the State agency upon request) a need for additional
information and how the extension is in the beneficiary's interest;
CMHSAS-SJC may extend the three (3) working day time period
by up to 14 calendar days.
3.
When a standard or expedited authorization of services decision is
extended, CMHSAS-SJC 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 appeal if he or she disagrees with that decision.
CMHSAS-SJC must issue and carry out its determination as expeditiously
as the enrollee's beneficiary's health condition requires and no later than
the date the extension expires
IX. NOTICE OF ACTION
A Notice of Action must be provided to a beneficiary when a service authorization
decision constitutes an "action" by authorizing a service in amount, duration or scope
less than requested or less than currently authorized, or the service authorization is not
made timely. In these situations, CMHSAS-SJC must provide a notice of action
containing additional information to inform the beneficiary of the basis for the action
CMHSAS-SJC has taken, or intends to take and the process available to appeal the
decision.
A.
Notice of Action requirements include:
1.
The notice of action to the beneficiary must be in writing and meet
language format needs of the individual to understand the content (i.e. the
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2.
3.
4.
5.
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format meets the needs of those with limited English proficiency and or
limited reading proficiency).
The requesting provider, in addition to the beneficiary, must be provided
notice of any decision by CMHSAS-SJC 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.
If a beneficiary or representative requests a local appeal, or a Medicaid
beneficiary requests a state fair hearing, not more than 12 calendar days
from the date of the notice of action, CMHSAS-SJC must reinstate the
services until disposition of the appeal.
If the beneficiary's services were reduced, terminated or suspended
without an advance notice, CMHSAS-SJC must reinstate services to the
level before the action.
If the utilization review function is not performed within part of 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 or individualized plan of services process still constitutes
an action, and requires a written notice of action.
The Notice of Action must be either Adequate or Advance:
1.
Adequate notice is a written notice provided to the beneficiary at the time
of EACH action. The individual plan of service, developed through a
person-centered planning process and finalized with the beneficiary, must
include, or have attached, the adequate notice provisions.
2.
Advance notice is a written notice required when an action is being taken
to reduce, suspend or terminate services that the beneficiary is currently
receiving. The advance notice must be mailed 12 calendar days before
the intended action takes effect.
3.
The content of both adequate and advance notices must include an
explanation of:
a.
What action CMHSAS-SJC has taken or intends to take.
b.
The reason(s) for the action.
c.
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.
d.
The beneficiary's or provider's right to file a CMHSAS-SJC
appeal, and instructions for doing so.
e.
The beneficiary's right to request a state fair hearing (for
beneficiaries with Medicaid), and instructions for doing so.
f.
The circumstances under which expedited resolution can be
requested, and instructions for doing so.
g.
An explanation that the beneficiary may represent himself or use
legal counsel, a relative, a friend or other spokesman.
4.
The content of an advance notice must also include an explanation of:
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b.
c.
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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.
There are limited exceptions to the advance notice requirement:
1.
CMHSAS-SJC may mail an adequate notice of action, not later than the
date of action to terminate, suspend or reduce previously authorized
services, if:
a.
CMHSAS-SJC has factual information confirming the death of the
beneficiary.
b.
CMHSAS-SJC receives a clear written statement signed by the
beneficiary 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.
c.
The beneficiary has been admitted to an institution where he/she is
ineligible (under Medicaid) for further services.
d.
The beneficiary's whereabouts are unknown and the post office
returns CMHSAS-SJC mail directed to him/her indicating no
forwarding address.
e.
CMHSAS-SJC establishes the fact that the beneficiary has been
accepted for services by another local jurisdiction, State, territory,
or commonwealth.
f.
The beneficiary’s physician prescribes a change in the level of
medical care.
g.
The date of the action will occur in less than 10 calendar days.
2.
The Notice of Action must be mailed within the following timeframes:
a.
At least 12 calendar days before the date of an action to
terminate suspend or reduce previously authorized covered
services(s) (Advance).
b.
At the time of the decision to deny payment for a service
(Adequate).
c.
Within 14 calendar days of the request for a standard service
authorization decision to deny or limit services (Adequate).
d.
Within 3 working days of the request for an expedited service
authorization decision to deny or limit services (Adequate).
3.
If CMHSAS-SJC is unable to complete either a standard or expedited
service authorization to deny or limit services within the timeframe
requirement, the timeframe may be extended up to an additional 14
calendar days. If CMHSAS-SJC extends the timeframe, it must:
a.
Give the beneficiary written notice, no later than the date the
current timeframe expires, of the reason for the decision to extend
the timeframe and inform the beneficiary of the right to file an
appeal if he or she disagrees with that decision.
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Issue and carry out its determination as expeditiously as the
beneficiary's health condition requires and no later than the date
the extension expires.
X. MEDICAID SERVICES CONTINUATION OF REINSTATEMENT
A.
CMHSAS-SJC must continue services previously authorized while the
CMHSAS-SJC appeal, and/or State fair hearing for Medicaid beneficiaries, are
pending if:
1.
The Beneficiary specifically requests to have the services continued.
2.
The Beneficiary or provider files the appeal timely.
3.
The appeal involves the termination, suspension, or reduction of a
previously authorized course of treatment.
4.
The services were ordered by an authorized provider.
5.
The original period covered by the original authorization has not expired.
B.
When CMHSAS-SJC continues or reinstates the beneficiary's services while the
appeal is pending, the services must be continued until one of the following
occurs:
1.
The beneficiary withdraws the appeal.
2.
Twelve calendar days pass after CMHSAS-SJC mails a “notice of
disposition” providing the resolution of the appeal against the beneficiary,
unless the Medicaid beneficiary, within the 12 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
Medicaid beneficiary.
4.
The time period or service limits of the previously authorized service has
been met.
C.
If CMHSAS-SJC, or the DCH fair hearing administrative law judge or MDCH
Dispute resolution process reverses a decision to deny authorization of services,
and the beneficiary received the disputed services while the appeal was pending,
CMHSAS-SJC or the State must pay for those services in accordance with State
policy and regulations.
D.
If CMHSAS-SJC, or the DCH fair hearing administrative law judge reverses a
decision to deny, limit, or delay services that were not furnished while the
appeal was pending, CMHSAS-SJC must authorize or provide the disputed
services promptly, and as expeditiously as the beneficiary's health condition
requires.
XI. STATE FAIR HEARING APPEAL PROCESS (MEDICAID BENEFICIARIES)
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A.
Federal regulations provide a Medicaid beneficiary the right to an impartial
review (fair hearing) by a state level administrative law judge, of a decision
(action) made by the local agency or its agent.
1.
A Medicaid beneficiary has the right to request a fair hearing when
CMHSAS-SJC or its contractor takes an "action", or if a grievance is not
acted upon within 60 calendar days.
2.
The Medicaid beneficiary does not have to exhaust local appeals before
he/she can request a fair hearing.
3.
The agency must issue a written notice of action to the affected
beneficiary (see section III above for Notice information).
4.
The agency may not limit or interfere with the beneficiary's freedom to
make a request for a fair hearing.
5.
Beneficiaries are given 90 calendar days from the date of the notice to
file a request for a fair hearing.
6.
If the beneficiary, or representative, requests a fair hearing not more than
12 calendar days from the date of the notice of action, CMHSAS-SJC
must reinstate the Medicaid services until disposition of the hearing by the
administrative law judge.
7.
If the Medicaid beneficiary's services were reduced, terminated or
suspended without advance notice, CMHSAS-SJC must reinstate services
to the level before the action.
8.
The parties to the state fair hearing include CMHSAS-SJC, the beneficiary
and his or her representative, or the representative of a deceased
beneficiary's estate.
9.
Expedited hearings are available.
10.
Detailed information and instructions for the Fair Hearing process can be
found in the DCH Administrative Tribunal Policy and Procedures Manual
online at www.michigan.gov/documents/Manual_9658_7.pdf.
B.
SWMBH coordinate and/or conduct the Fair Hearing for Administrative Tribunal
Hearings for Medicaid beneficiaries of the CMHSAS-SJC.
XII.
LOCAL APPEAL PROCESS
A.
Federal regulations provide a Medicaid beneficiary the right to a local level
appeal of an action. Persons who do not have Medicaid are entitled to a local
dispute resolution/appeal process, which must first be exhausted before accessing
the MDCH Dispute Resolution Process. While the CMHSAS-SJC has overall
responsibility for the Medicaid local appeal process, the individual CMHSP’s will
be responsible for the grievance and appeals process for non-Medicaid individuals
receiving services and for certain functions for Medicaid beneficiaries identified
in the CMHSAS-SJC Delegation Agreements.
B.
CMHSAS-SJC appeals, like those for fair hearings, are initiated by an "action".
The beneficiary may request a local appeal under the following conditions:
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2.
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The beneficiary has 45 calendar days from the date of the notice of action
to request a local appeal. An oral request for a local appeal of an action 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.
The Medicaid beneficiary may file an appeal with the CMHSAS-SJC
organizational unit approved and administratively responsible for
facilitating local appeals.
If the beneficiary, or representative, requests a local appeal not more than
12 calendar days from the date of the notice of action, the CMHSAS-SJC
must reinstate or continue the services until disposition of the hearing.
C.
When a beneficiary requests a local appeal, the CMHSAS-SJC is required to:
1.
Give beneficiaries 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/TTD
and interpreter capability.
2.
Acknowledge receipt of each appeal.
3.
Maintain a log of all requests for appeal to allow reporting to the
CMHSAS-SJC Quality Improvement Program and Customer Services.
4.
Ensure that the individuals who make the decisions on appeal were not
involved in the previous level review or decision-making.
5.
Ensure that the individual(s) who make the decisions on appeal are health
care professionals with appropriate clinical expertise in treating the
beneficiary'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 beneficiary, 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
beneficiary's case file, including medical records and any other
documents or records considered during the appeals process.
c.
Opportunity to include as parties to the appeal the beneficiary and
his or her representative or the legal representative of a deceased
beneficiary's estate.
d.
Information regarding the right to a fair hearing (Medicaid
beneficiary) and the process to be used to request the hearing.
e.
Information regarding the right to the MDCH Dispute Resolution
process (non-Medicaid beneficiary) and the process to be used to
request the hearing.
D.
Notice of Disposition requirements:
1.
The CMHSAS-SJC must provide written notice of the disposition of the
appeal, and must also make reasonable efforts to provide oral notice of an
expedited resolution.
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3.
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The content of a notice of disposition must include an explanation of the
results of the resolution and the date it was completed.
When the appeal is not resolved wholly in favor of the beneficiary, the
notice of disposition must also include:
a.
The right for a Medicaid beneficiary to request a state fair hearing,
and how to do so.
b.
The right for a Non-Medicaid beneficiary to request MDCH
Dispute Resolution, and how to do so.
c.
The right to request to receive benefits while the state fair hearing
or MDCH Dispute Resolution is pending, if requested within 12
days of the KCMHSAS mailing the notice of disposition, and how
to make the request.
d.
That the beneficiary may be held liable for the cost of those
benefits if the hearing decision upholds the CMHSAS-SJC action.
The Notice of Disposition must be provided within the following timeframes:
1.
Standard Resolution
CMHSAS-SJC must resolve the appeal and provide notice of disposition
to the affected parties as expeditiously as the beneficiary's health condition
requires, but not to exceed 45 calendar days from the day CMHSAS-SJC
receives the appeal.
2.
Expedited Resolution
CMHSAS-SJC must resolve the appeal and provide notice of disposition
to the affected parties no longer than three (3) working days after
CMHSAS-SJC receives the request for expedited resolution of the appeal.
a.
An expedited resolution is required when CMHSAS-SJC
determines (for a request from the beneficiary) or the provider
indicates (in making the request on behalf of, or in support of the
beneficiary's request) that taking the time for a standard resolution
could seriously jeopardize the beneficiary's life or health or ability
to attain, maintain, or regain maximum function.
b.
CMHSAS-SJC may extend the notice of disposition timeframe by
up to 14 calendar days if the beneficiary requests an extension, or
if CMHSAS-SJC shows to the satisfaction of the state that there is
a need for additional information and how the delay is in the
beneficiary's interest.
3.
If CMHSAS-SJC denies a request for expedited resolution of an appeal, it
must:
a.
Transfer the appeal to the timeframe for standard resolution or no
longer than 45 days from the date CMHSAS-SJC KCMHSAS
receives the appeal.
b.
Make reasonable efforts to give the beneficiary prompt oral
notice of the denial.
c.
Give the beneficiary follow up written notice within two (2)
calendar days.
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XIII. LOCAL GRIEVANCE PROCESS
A.
Federal regulations provide Medicaid beneficiaries the right to a local grievance
process for issues that are not "actions". Persons who do not have Medicaid are
also entitled to a local grievance process. The CMHSAS-SJC policy will apply to
both Medicaid and Non-Medicaid beneficiaries.
B.
Beneficiary grievances:
1.
Shall be filed with the CMHSAS-SJC organizational unit approved and
administratively responsible for facilitating resolution of the grievance.
2.
May be filed at any time by the beneficiary, guardian, or parent of a minor
child or his/her legal representative.
3.
Do not have access to the state fair hearing process (Medicaid
beneficiaries) unless, CMHSAS-SJC fails to respond to the grievance
within 60 calendar days. This constitutes an "action", and can be
appealed for fair hearing to the MDCH Administrative Tribunal.
4.
Do not have access to the MDCH Dispute Resolution process (nonMedicaid Beneficiaries) unless, CMHSAS-SJC fails to respond to the
grievance within 60 calendar days. This constitutes an "action", and can
be appealed to the CMHSP for a local appeal, after which time can be
appealed for dispute resolution through the MDCH Dispute Resolution
process.
C.
For each grievance filed by a beneficiary, CMHSAS-SJC is required to:
1.
Give the beneficiary 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/TTD
and interpreter capability.
2.
Acknowledge receipt of the grievance.
3.
Log the grievance for reporting to CMHSAS-SJC Quality Improvement
Program and Customer Services.
4.
Ensure that the individual(s) who make the decisions on the grievance
were not involved in the previous level review or decision-making.
5.
Ensure that the individual(s) who make the decisions on the grievance are
health care professionals with appropriate clinical expertise in treating the
beneficiary's condition or disease if the grievance:
a.
Involves clinical issues
b.
Involves the denial of an expedited resolution of an appeal (of an
action)
D.
Submit the written grievance to appropriate staff including a CMHSAS-SJC
administrator with the authority to require corrective action, none of who shall
have been involved in the initial determination.
E.
Provide the beneficiary a written notice of disposition not to exceed 60 calendar
days from the day CMHSAS-SJC received the grievance/complaint.
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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.
The Medicaid beneficiary's right to request a local appeal or a fair
hearing if the notice of disposition is more than 60 days from the
date of the request for a grievance.
d.
The non- Medicaid beneficiary's right to request a local appeal if
the notice of disposition is more than 60 days from the date of the
request for a grievance.
e.
How to access the fair hearing process.
XIV. RECORD KEEPING REQUIREMENTS
A.
CMHSAS-SJC is required to maintain Grievance System records of beneficiary
appeals and grievances for review by State staff as part of the State quality
strategy and according to CMHSAS-SJC delegation agreement. CMHSAS-SJC
Grievance System records should contain sufficient information to accurately
reflect.
1.
The process in place to track requests for Medicaid services denied by
CMHSAS-SJC or any of its providers.
2.
The volume of denied claims for services in the most recent year.
B.
A complete record of all requests for grievance, appeals and second opinions shall
be maintained by CMHSAS-SJC and shall include at a minimum the:
1.
Original request for the appeal, grievance, or second opinion.
2.
Original Hearing or Dispute Resolution request.
3.
Correspondence related to any resolution or settlement offers.
4.
All documentation, records, correspondence used to determine resolution.
5.
Final agreement on any resolution/settlement offers.
6.
Copy of the hearing/dispute resolution summary completed for the appeal
process.
7.
Written results or outcome provided by the CMHSAS-SJC,
Administrative Tribunal or the MDCH.
8.
Results of any other appeals or Recipient Rights complaints filed related
to the appeal, grievance, second opinion or Hearing/Dispute Resolution
request.
XV.
RECIPIENT RIGHTS COMPLAINT PROCESS
Medicaid and Non-Medicaid persons receiving mental health services, have rights to file
Recipient Rights complaints under the authority of the State Mental Health Code.
Recipient Rights complaint requirements are articulated in CMHSP Managed Mental
Health Supports and Services contract, Attachment C6.3.2.1 CMHSP Local Dispute
Resolution Process.
XVI. SECOND OPINION PROCESS
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A.
Medicaid and Non-Medicaid beneficiaries have rights to a Second Opinion review
under authority of the State Mental Health Code. The Second Opinion review
process may be requested for denial of Inpatient Hospitalization and for denial of
CMHSAS-SJC services, under sections 409 and 705 of the Michigan Mental
Health Code. While the process of notification of right to a second opinion is
delegated to each CSSN, the function of performing the Second Opinion lies with
the CMHSAS-SJC Chief Executive Director for all Medicaid beneficiaries.
B.
For each denial of inpatient care or eligibility for CMHSAS-SJC service, at the
time of the denial, CMHSAS-SJC is required to provide the beneficiary with a
written Adequate Notice of Action and a notice of the right to a Second Opinion
process. The Notice shall contain all information as identified in Sections III, V
and VIII of this policy. In addition, the Notice must also indicate that the
beneficiary is entitled to request a second opinion and the process for doing so.
C.
Second Opinion Requests, Inpatient Denial (409):
1.
For Second Opinion requests regarding denial of inpatient psychiatric care
for Medicaid beneficiaries, the CSSN shall immediately verbally, and
within 1 working day in writing, notify the CMHSAS-SJC Chief
Executive Director. For second opinion requests for inpatient psychiatric
care for non-Medicaid beneficiaries, the CSSN Executive Director shall
respond according to CSSN policy.
2.
For all Medicaid and CMHSAS-SJC beneficiary requests for Second
Opinion reviews, the CMHSAS-SJC Chief Executive Director shall
arrange for an additional evaluation by a psychiatrist, other physician, or
licensed psychologist to be performed within 3 days, excluding Sundays
and holidays, after the CMHSAS-SJC Chief Executive Director receives
the request.
3.
If the conclusion of the second opinion is different from the conclusion of
the pre-admission screening unit, the CMHSAS-SJC Chief Executive
Director, in conjunction with CMHSAS-SJC Chief Medical Director, shall
make a decision based on all available clinical information within 1
business day of receiving the conclusion of the review. The CMHSASSJC Chief Executive Director’s decision shall be confirmed in writing to
the individual who requested the second opinion, and the confirming
document shall include the signatures of the ED and the CMD or
verification that the decision was made in conjunction with the CMD.
4.
If the beneficiary is assessed and found not to be clinically suitable for
hospitalization, the CMHSAS-SJC shall provide appropriate referral
services and applicable written notices of disposition and Appeal, Hearing
and Dispute Resolution rights/processes in accordance with Sections III, V
and VIII of this policy.
D.
Second Opinion Requests, Community Mental Health Services, (705):
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2.
3.
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23.01
For Second Opinion requests regarding denial of CMHSP services for
Medicaid beneficiaries, the CSSN shall immediately verbally, and within
1 working day in writing, notify the CMHSAS-SJC Chief Executive
Director. For second opinion requests regarding denial of CMHSP
services for non-Medicaid beneficiaries, the CSSN Executive Director
shall respond according to CSSN policy.
For all Medicaid and CMHSAS-SJC applicants for community mental
health services who have been denied mental health services, the
applicant, his/her guardian if one has been appointed, or the applicant’s
parent or parents if the applicant is a minor, may request a second opinion
of the CMHSAS-SJC Chief Executive Director.
The CMHSAS-SJC Chief Executive Director shall secure the second
opinion from a physician, licensed psychologist, registered professional
nurse, master’s level social worker or master’s level psychologist for any
PIHP/CMH eligibility issues other than inpatient care. Unless involved in
the original denial, this person typically shall be the CMHSAS-SJC
Deputy Director of Access and Utilization, but will be at the CMHSASSJC Chief Executive Director’s discretion.
If the individual providing the second opinion determines that the
applicant has a serious mental illness, serious emotional disturbance, or a
developmental disability or is experiencing an emergency or urgent
situation, the CMHSAS-SJC shall direct services to the applicant.
If the beneficiary is assessed and found not to be clinically suitable for
CMHSAS-SJC services and supports, the CMHSAS-SJC shall provide
appropriate referral services and applicable written notices of disposition
and Appeal, Hearing and Dispute Resolution rights/processes in
accordance with Sections III, V and VIII of this policy.
XVII. REPORTING REQUIREMENTS
The CMHSAS-SJC shall monitor, track and trend all denials, fair hearing, grievance and
appeals and second opinion requests and dispositions.
XVIII. PROCEDURES
CMHSAS-SJC will establish procedures for distribution of Action Notices and local
grievance and appeal processes as delegated by the SWMBH.
REFERENCES
-
Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c)
Waiver Program Section 3.1.1
-
Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c)
Waiver Program; Attachment P3.1.1
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Southwest Michigan Behavioral Health Policy

6.4 (Customer Grievance Systems)
EXHIBITS
A.
Action Notice and Hearing Rights – Medicaid (English & Spanish)
B.
Action Notice – Non-Medicaid (English & Spanish)
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23.01