LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 200.04 Beneficiary Problem Resolution Process
 
Policy Category:  Clinical
Distribution Level:  Directly Operated and Contractor
Responsible Party:  Patients' Rights Office

Approved by Curley L. Bonds, MD, Chief Medical Officer
Reviewed and approved by Clinical Policy Committee on Sep 26, 2024
I.  PURPOSE
 
To ensure that a Medi-Cal beneficiary’s grievances and appeals within the Los Angeles County Department of Mental Health (DMH/Department) regarding Specialty Mental Health Services (SMHS) are addressed in a sensitive, timely, appropriate, and culturally competent manner.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 
II.  DEFINITIONS
 
Appeal: A request by the beneficiary, or provider, or their authorized representative for the review of an Adverse Benefit Determination described in a Notice of Adverse Benefit Determination (NOABD) letter.

Beneficiary: Any person certified as eligible for services under the Medi-Cal program.

Discrimination Grievance:  An expression of dissatisfaction, by all beneficiaries, prospective beneficiaries, and members of the public, about any concern of discrimination based on sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation.

Grievance: An expression of dissatisfaction about any matter other than an Adverse Benefit Determination. There is no distinction between an informal and formal grievance.

Exempt Grievance: An expression of dissatisfaction about any matter which is resolved by the close of the next business day following receipt.

Expedited Appeal: An appeal used when the Department determines or the beneficiary and/or beneficiary’s provider indicates that following the time frame for a standard appeal as established would seriously jeopardize the beneficiary’s mental health or substance use disorder condition and/or the beneficiary’s ability to attain, maintain, or regain maximum function.

Notice of Adverse Benefit Determination (NOABD):  A written notice to the beneficiary when the Department takes an action on:
  1. Denial or limited authorization of a requested service, including determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
  2. The reduction, suspension, or termination of a previously authorized service;
  3. The denial, in whole or part, of payment for a service;
  4. The failure to provide services in a timely manner;
  5. The failure to act within the required timeframes for standard resolution of grievances and appeals; or
  6. The denial of a beneficiary’s request to dispute financial liability.
 
Specialty Mental Health Services: In accordance with CCR Title 9 § 1810.247:
  1. Rehabilitative services, including mental health services, medication support services, day treatment intensive, day rehabilitation, crisis intervention, crisis stabilization, adult residential treatment services, crisis residential treatment services, and psychiatric health facility services;
  2. Psychiatric inpatient hospital services;
  3. Targeted Case Management;
  4. Psychiatrist and Psychologist services;
  5. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Supplemental Specialty Mental Health Services; and,
  6. Psychiatric nursing facility services.
 
Medi-Cal State Fair Hearing: An independent review conducted by the California Department of Social Services (CDSS), the final arbiter of appeals for actions taken by the Department. Beneficiaries must exhaust the Department's appeal process prior to requesting a State Fair Hearing.
 
III.  POLICY
 
Medi-Cal beneficiaries who are dissatisfied with SMHS may register and pursue grievances. 
  • Beneficiaries may appeal a decision by the Department when services are denied, terminated, suspended, or reduced.
DMH shall comply and operate with all applicable federal grievance and appeal system requirements, State regulations, and DMH policies when processing NOABDs and grievances for SMHS.
  • The Department shall provide a timely and adequate written NOABD when taking any of the actions defined in the NOABD definition (42 CFR 438.10).
DMH shall not discourage the filing of grievances and appeals.

DMH shall not take any punitive action against the provider for requesting grievances or appeals on the beneficiary's behalf.

DMH shall capture every complaint as an expression of dissatisfaction without requiring the beneficiary to use the specific term “grievance.” 

Even if a beneficiary expressly declines to file a formal grievance, DMH shall record their complaint and it shall still be categorized as a grievance. As with other grievances, Patients' Rights Office (PRO) shall analyze these grievances to monitor trends by each clinic.

DMH shall accept a grievance or appeal, verbally or in writing, from a beneficiary or a provider and/or authorized representative. 

DMH shall not require a beneficiary to file a Discrimination Grievance with DMH before filing the complaint directly with the DHCS Office of Civil Rights and the U.S. Health and Human Services Office for Civil Rights. PRO shall be the Discrimination Grievance unit for DMH.
 
IV.  PROCEDURES
 
Procedures - Beneficiary Problem Resolution Process
 
V.  AUTHORITIES
 
VI.  ATTACHMENTS