Member Intent to File a Grievance

This “Intent to File a Grievance” is an expression of dissatisfaction about any matter other than an Adverse Benefit Determination. Grievances may include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, failure to respect the member’s rights regardless of whether remedial action is requested, and the member’s right to dispute an extension of time proposed by the Behavioral Health Plan (BHP) to make an authorization decision. There is no distinction between an informal and formal grievance. A complaint shall be considered a grievance unless it meets the definition of an “Adverse Benefit Determination”.

The “Intent to File an Appeal” form is to request review of a decision when services are denied, reduced, or terminated and/or if there has been an inappropriate delay in service or in the Problem Resolution Process. An Appeal must be filed within 60 days of the date of the Notice of Action. Appeals will be addressed within 30 days of filing, unless expedited (i.e. waiting will jeopardize life, health or ability to maintain or regain maximum function).

For expedited resolution of an appeal and notice to affected parties (i.e., the member, authorized representative and/or provider), the BHP shall resolve the appeal, and provide notice, as expeditiously as the member’s health condition requires, but no longer than 72 hours after the BHP receives the request for expedited resolution. (Contact the Patients’ Rights Advocate regarding Expedited Appeals.)

Intent to File a Grievance and Intent to File an Appeal forms can be found in the provider lobby, requested from the Patients’ Rights Advocate, or online. Written confirmation that your grievance was received will be sent within five calendar days. Grievances and Appeals will be resolved in 30 calendar days of filing.

For information regarding an Appeal and/or a Grievance or to file a Grievance orally, please contact the Patients’ Rights Advocate at 530-265-1437. For more detailed information, reference the Client Problem Resolution Guide or the Nevada County Integrated MHP and DMC ODS Handbook.

Members have 120 days from the date of the county’s written appeal decision notice to request a State Fair Hearing. Members can file for a State Fair Hearing if you filed an appeal and received an appeal resolution letter telling you that your county denied your appeal request or your grievance, appeal, or expedited appeal wasn’t resolved in time. You can request a State Fair Hearing:

Online: https://acms.dss.ca.gov/acms/login.request.do,

In writing: California Department of Social Services State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430

By fax: 916-651-5210 or 916-651-2789

By telephone: 1-800-743-8525 or 1-855-795-0634.

I _____________________,

First NameLast Name

am informing the

Provider (enter provider name below)

Are you a...

Name

Phone

Phone NumberFormat: (000) 000-0000.

Email

example@example.com

Check if Unhoused

Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth

MonthDayYear

Medi-Cal #

Nature of Grievance date occurrence location individual(s) involved

0/2048

What steps if any did you take to resolve the issue (whom did you talk to when and what response did you get):

0/2048

Is this grievance related to Transgender, Gender Diverse, or Intersex discrimination?

I give permission to contact me about this matter via text message or email.

Date Signed

MonthDayYear

Signature

Member Intent to File a Grievance

of my request to initiate Grievance Proceedings regarding the provision of services at your facility. I understand that I will not be subject to discrimination or any other penalty for filing an Appeal. My printed information is as follows:

Signature