Beneficiary Protections & Problem Resolution

Problem Resolution

The problem resolution process enables a client, also known as a beneficiary (or their authorized representative) to resolve a problem or concern about any issue related to Behavioral Health's performance, including the delivery of specialty mental health services. The Beneficiary Problem Resolution process includes:

Grievances

A grievance is a beneficiary's verbal or written expression of dissatisfaction with Behavioral Health about any matter, other than a matter covered by an appeal. Behavioral Health must review and provide a determination on a grievance within 90 calendar days of the receipt of the grievance (this time frame may be extended by up to 14 calendar days under certain circumstances).

Appeals

An appeal is a beneficiary’s verbal or written (verbal requests must be followed up in writing) request to Behavioral Health for review of an “action” taken by Behavioral Health. Behavioral Health must decide on the appeal and notify the beneficiary of that decision within 30 calendar days of the receipt of the appeal (this time frame may be extended up to 14 calendar days under certain circumstances).

An "action" occurs when Behavioral Health:

  • Denies, modifies, reduces, or terminates a provider's request for payment authorization of a covered specialty mental health service;
  • (or its provider) Determines that the beneficiary does not meet specialty mental health services medical necessity criteria and therefore will not receive specialty mental health services;
  • Fails to provide a specialty mental health service within the time frame for delivery of the service; or
  • Fails to act within the time frames for resolution of grievances, appeals, or the expedited appeals.

Expedited Appeal

An expedited appeal allows the beneficiary to request a review of an action that may seriously jeopardize the beneficiary's life, health, or ability to attain, maintain, or regain maximum function. Beneficiaries may request expedited appeals verbally without following up the request in writing. Behavioral Health must decide on the expedited appeal and notify the beneficiary of that decision within 3 working days of the receipt of the expedited appeal (this time frame may be extended by up to 14 calendar days under certain circumstances).

If a beneficiary disagrees with the decision surrounding the appeal or expedited appeal, the beneficiary may request a State Fair Hearing, or an Expedited State Fair Hearing.

For more information on the Beneficiary Problem Resolution Process or to file a grievance or appeal, please contact the Patients’ Rights Advocate.

Patients Rights Advocate Contact

1196 East Lassen Avenue
Suite 130
Chico, CA 95973
Phone: 530-343-1731
Phone: 800-497-1445
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