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. There is no deadline for filing an Appeal when no Notice of Action was sent. Expedited Appeals must be requested (verbally or in writing) within 10 days. 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 business days. 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.