LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 200.04 Beneficiary Problem Resolution Process
 
  PROCEDURES
    1. DMH Patients' Rights Office (PRO) shall provide to the beneficiary receipt of the grievance in writing. The acknowledgment letter shall include the date of receipt, name, telephone number, and address of the Department representative who the beneficiary may contact about the grievance. The written acknowledgment shall be postmarked within five (5) calendar days of receipt of the grievance.
       
    3. PRO shall resolve a grievance and notify the beneficiary of the disposition.
       
    4. The timeframe for resolving grievances related to disputes of the decision to extend the timeframe for making an authorization decision shall not exceed 90 calendar days.

      PRO shall use the Notice of Grievance Resolution (NGR) to notify beneficiaries of the results of the grievance resolution. The NGR shall contain a clear and concise explanation of the DMH's decision.
       
    5. PRO can extend the timeframe for an additional 14 calendar days if the beneficiary requests the extension or the Department proves that additional information and the delay is in the beneficiary’s interest. In this event PRO shall provide the beneficiary with the applicable Notice of Adverse Benefit Determination, and include the status of the grievance and the estimated date of resolution, which shall not exceed 14 additional calendar days.
       
      1. If PRO extends the timeframe, not at the request of the beneficiary, PRO must complete all of the following:
         
        1. Give the beneficiary prompt verbal notice of the delay;
        2. Within two (2) calendar days of making the decision, give the beneficiary written notice of the reason for the decision to extend the timeframe and inform the beneficiary of the right to file a grievance if they disagrees with that decision; and
        3. Resolve the grievance no later than the date the extension expires.
           
    1. PRO grievances received over the telephone or in-person which are resolved to the beneficiary’s satisfaction by the close of the next business day following receipt are exempt from the requirement to send a written acknowledgment and disposition letter.
       
    2. Grievances received by PRO are not exempt from the requirement to send an acknowledgment and disposition letter in writing.
       
    3. If PRO receives a complaint pertaining to a Notice of Adverse Benefit Determination (NOABD), the complaint is not considered a grievance and the exemption does not apply.
       
    4. PRO shall maintain a log of all grievances containing the date of receipt of the grievance, the name of the beneficiary, the nature of the grievance, the resolution, and the PRO representative's name who received and resolved the grievance.
       
    5. PRO shall transmit issues identified as a result of the grievance, appeal, or expedited appeal processes to DMH's Countywide Quality Improvement Committee.
       
    6. PRO shall ensure exempt grievances are included in its Beneficiary Grievance and Appeal Report that is submitted to the Department of Health Care Services (DHCS).
  3. Appeals
     
    1. Beneficiaries are required to file an appeal within 60 calendar days from the date on the NOABD. Beneficiaries must also exhaust the PRO appeal process prior to requesting a State hearing.
       
    2. The beneficiary, or a provider and/or authorized representative, may request an appeal either orally or in writing. Appeals filed by the provider on behalf of the beneficiary require written consent from the beneficiary.
       
    3. In addition, an oral appeal (excluding expedited appeals) shall be followed by a written appeal signed by the beneficiary. The date of the oral appeal establishes the filing date for the appeal. PRO, directly operated programs, and contracted agencies shall request that the beneficiary’s oral request for a standard appeal be followed by written confirmation unless the beneficiary or provider requests expedited resolution in accordance with federal regulations.
       
    4. PRO shall assist the beneficiary in completing forms and taking other procedural steps to file an appeal, including preparing a written appeal, notifying the beneficiary of the location of the form on the Department's website, or providing the form to the beneficiary upon request.
       
    5. PRO shall assist the beneficiary in requesting continuation of benefits during an appeal of the adverse benefit determination in accordance with federal regulations. In the event that the PRO does not receive a written and signed appeal from the beneficiary, the PRO shall neither dismiss nor delay resolution of the appeal.
       
    6. With written consent of the beneficiary, PRO, a directly operated program, contract agency, or authorized representative shall file a grievance, request an appeal, or request a State hearing on behalf of the beneficiary. Providers and authorized representatives cannot request continuation of benefits, as specified in 42 CFR § 438.420(b)(5).
       
    7. There is only one level of appeal for the beneficiary.  
       
  4. Standard Resolution of Appeals
     
    1. PRO shall provide the beneficiary with a written acknowledgment of receipt of the appeal.
       
      1. The acknowledgment letter shall include the date of receipt, as well as the name, telephone number, and address of the PRO representative who the beneficiary may contact about the appeal.
         
      2. The written acknowledgment to the beneficiary shall be postmarked within five (5) calendar days of receipt of the appeal.
         
      3. PRO shall resolve an appeal within 30 calendar days of receipt.
         
    2. PRO may extend the resolution timeframes for appeals by up to 14 calendar days if either of the following two conditions apply:
       
      1. The beneficiary requests the extension; or
         
    3. For any extension not requested by the beneficiary, PRO is required to provide the beneficiary with written notice of the reason for the delay. PRO shall make reasonable efforts to provide the beneficiary with prompt oral notice of the extension.
       
      1. PRO shall provide written notice of the extension within two (2) calendar days of making the decision to extend the timeframe and notify the beneficiary of the right to file a grievance if the beneficiary disagrees with the extension. 
         
    4. PRO shall resolve the appeal as expeditiously as the beneficiary’s health condition requires and in no event extend the resolution beyond the 14 calendar day extension.
       
      1. In the event that PRO fails to adhere to the notice and timing requirements, the beneficiary is deemed to have exhausted the Department's appeal process and may initiate a State hearing.
         
  5. Expedited Resolution of Appeals
     
    1. PRO shall resolve the appeal, and provide notice, as expeditiously as the beneficiary’s health condition requires, no longer than 72 hours after PRO receives the expedited appeal request.
       
    2. If PRO denies a request for expedited resolution of an appeal, it must transfer the appeal to the timeframe for standard resolution. In addition, PRO shall complete all of the following actions:
       
      1. PRO shall make reasonable efforts to provide the beneficiary with prompt oral notice of the decision to transfer the appeal to the timeframe for standard resolution;
         
      2. PRO shall provide written notice of the decision to transfer the appeal to the timeframe for standard resolution within two (2) calendar days of making the decision and notify the beneficiary of the right to file a grievance if the beneficiary disagrees with the extension; and
         
      3. PRO shall resolve the appeal as expeditiously as the beneficiary’s health condition requires and within 30 days of receipt of the appeal.
         
  6. Notice of Appeal of Resolution (NAR) - Adverse Benefit Determination Upheld
     
    1. For appeals not resolved wholly in favor of the beneficiary, PRO shall utilize a NAR form which is comprised of two components:
       
      1. Notice of Appeal Resolution and
         
      2. “Your Rights” attachment
         
    2. PRO shall send written NARs to beneficiaries and include the following:
       
      1. Results of the resolution and the date it was completed;
         
      2. Reasons for the determination, including the criteria, clinical guidelines, or policies used in reaching the determination; and
         
      3. For appeals not resolved wholly in the favor of the beneficiary, the right to request a State hearing and how to request it;
         
      4. For appeals not resolved wholly in the favor of the beneficiary, the right to request and receive benefits while the hearing is pending and how to make the request; and
         
      5. Notification that the beneficiary may be held liable for the cost of those benefits if the hearing decision upholds the adverse benefit determination.
         
  7. Adverse Benefit Determination Overturned
     
    1. For appeals resolved wholly in favor of the beneficiary, PRO shall provide written notice to the beneficiary, which shall include the results of the resolution and the date it was completed. Plans shall also ensure that the written response contains a clear and concise explanation of the reason, including why the decision was overturned. 
       
    1. Beneficiaries must exhaust PRO's appeal process prior to requesting a State hearing.
       
    2. A beneficiary has the right to request a State hearing only after receiving notice that PRO is upholding an adverse benefit determination.
       
    3. Beneficiaries can request a State hearing within 120 calendar days from the date of the NAR, which informs the beneficiary that the Adverse Benefit Decision has been upheld.
       
  9. Grievance and Appeal System
     
    1. PRO, directly operated programs, and contracted agencies shall record all grievances and appeals in the Grievance, Appeal, and Expedited Appeal Database to ensure the receipt, review, and resolution of grievances and appeals.
       
    2. PRO shall notify beneficiaries about the Grievance and Appeal System and shall include procedures for filing and resolving grievances and appeals, the local telephone number (213-738-4949), and the address for mailing grievances and appeals (Patients' Rights Office, 510 S. Vermont Avenue, 21st Floor, Los Angeles, CA 90020).
       
    3. PRO, directly operated programs, and contracted agencies shall make Grievance, Appeal, and Expedited Appeal forms with self-addressed envelopes available to beneficiaries at every provider site. 
       
      1. Forms shall be accessible at each provider site without making a verbal or written request to anyone.
         
      2. A description of the procedure for filing grievances and appeals shall be readily available at each facility of the Plan, on the Department's website, and at each contracting provider's office or facility, posted in a location that is accessible to beneficiaries.
         
    4. PRO, directly operated programs, and contracted agencies shall assist beneficiaries with filing grievances and appeals at each location where grievances and appeals are submitted. Grievance and appeal forms shall be provided promptly upon request.
       
    5. Beneficiaries shall not be discriminated against because they filed a grievance or appeal.
       
    6. PRO shall maintain a written record for each grievance and appeal received, including the following information:
       
      1. The date and time of receipt of the grievance or appeal;
         
      2. The name of the beneficiary filing the grievance or appeal;
         
      3. The name of the representative recording the grievance or appeal;
         
      4. A description of the complaint or problem;
         
      5. A description of the action taken by PRO, directly operated program, or contracted agency to investigate and resolve the grievance or appeal;
         
      6. The proposed resolution by PRO, directly operated program, or contracted agency;
         
      7. The name of the staff responsible for resolving the grievance or appeal; and
         
      8. The date of notification to the beneficiary of the resolution.
         
      1. The Countywide Quality Improvement Committee shall review all grievances and appeals.
         
      2. The Countywide Quality Improvement Committee shall initiate appropriate action to remedy any problems identified.
         
    8. The person making the final decision for the proposed resolution of a grievance or appeal shall not participate in any prior decisions related to the grievance or appeal.  Additionally, the decision-maker shall be a health care professional with clinical expertise in treating a beneficiary’s condition or disease if any of the following apply:
       
      1. An appeal of an Adverse Benefit Determination that is based on lack of medical necessity;
         
      2. A grievance regarding denial of an expedited resolution of an appeal; or
         
      3. Any grievance or appeal involving clinical issues.
         
    9. PRO shall ensure that individuals making decisions on clinical appeals take into account all comments, documents, records, and other information submitted by the beneficiary or the beneficiary’s authorized representative, regardless of whether such information was submitted or considered in the initial Adverse Benefit Determination.
       
    10. PRO shall provide the beneficiary or beneficiary’s authorized representative the opportunity to review the beneficiary’s case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the Department in connection with any standard or expedited appeal of an Adverse Benefit Determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe.
       
    11. PRO shall provide the beneficiary or authorized representative a reasonable opportunity, in person and in writing, to present evidence and testimony. PRO shall inform the beneficiary or authorized representative of the limited time available for this sufficiently in advance of the resolution timeframe for appeals, as specified, and in the case of expedited resolution.
       
    12. PRO shall address the linguistic and cultural needs of its beneficiary population, as well as the needs of beneficiaries with disabilities.  PRO shall ensure all beneficiaries have access to and can fully participate in the Grievance and Appeal System by assisting those with limited English proficiency or with visual or other communicative impairments.  Such assistance shall include but is not limited to, translations of grievances and appeals procedures, forms, and PRO responses to grievances and appeals, as well as access to interpreters, telephone relay systems, and other devices that aid individuals with disabilities to communicate.
       
    13. Within ten calendar days of mailing a Discrimination Grievance resolution letter to a beneficiary, PRO must submit the following information regarding the complaint to the DHCS Office of Civil Rights:  
      • The original complaint
        The provider's or other accused party's response to the complaint.
      • Contact information for the personnel primarily responsible for investigating and responding to the complaint on behalf of DMH.
        Contact information for the beneficiary filing the complaint, and for the provider or other accused party that is the subject of the complaint.
      • All correspondence with the beneficiary regarding the complaint, including, but not limited to, the Discrimination Grievance.
      • The results of PRO's investigation, copies of any corrective action taken, and any other information that is relevant to the allegation(s) of discrimination.