POL-102.01    COMPLAINT, GRIEVANCE, APPEAL, AND FAIR HEARING POLICY

It is the policy of the North Sound Mental Health Administration (NSMHA) to resolve complaints, grievances and appeals at the lowest possible level, in a confidential manner and without retaliation.  The NSMHA policy is to resolve or rule upon, if necessary, consumers (see definition of “consumer” below) complaints and grievances honoring consumer’s voice, choice, and rights while considering most effective clinical practices, medical necessity, laws, and federal/state/and RSN contractual requirements.

Although the NSMHA encourages the resolution of complaints, grievances, and appeals of service determinations at the lowest possible level, consumers may initiate a grievance or appeal with the NSMHA without first utilizing the complaint process.  Consumers may file for fair hearing without first utilizing the complaint, grievance, or appeal process.  When a consumer wishes to request disenrollment from the prepaid health plan for good cause they must first utilize the Grievance Process (PRO 102B.01) included in this NSMHA complaint and grievance policy. (For information about Disenrollment see North Sound Mental Health Administration Disenrollment Policy 103). The Privacy Officer will be informed of any complaint that relates to NSMHA Privacy practices. The Privacy Officer will document all Privacy complaints received and their disposition.

1. Consumers will be informed of their right to initiate a complaint, grievance, appeal, or request a fair hearing.  This policy will be published and made available to all current and potential users of publicly funded mental health services, and advocates in language that is clear and understandable to the individual.  The NSMHA Notice of Privacy Practices will contain a statement that individuals may complain to the NSMHA and to the Secretary of Health and Human Services if they believe their privacy rights have been violated, a brief description of how the individual may file a complaint with the covered entity, and a statement that the individual will not be retaliated against for filing a complaint.

2. Consumers will receive written notification of all service determinations, the criteria used to make the determinations, and the steps to appeal these determinations.

3. Consumers may have participation of others at their choice throughout the process.

4. Current services will continue while complaints, grievances or appeals or fair hearings are in progress.

5. Confidential ombuds services are available to assist consumers, toll free, at 1-888-336-6164.   Ombuds services will be offered to assist consumers at all levels of this process.

6.  Interpreter services, TTY/TDD, and mental health specialists are available throughout the process to ensure culturally competent processes.

7.  Complaints will be handled in a confidential manner.

8. There will be no retaliation or punitive action of any kind against a consumer who initiates a complaint, grievance, appeal, or request for fair hearing.  Ombuds, provider, and NSMHA staff are available to assist if concerns about retaliation occur.

9.  Aggregate information about types of complaints, grievances, appeals, and fair hearing requests will be used to analyze trends and identify areas for quality improvement.

10.  The following definitions will apply to the entire Policy 102.01, and Procedures 102A.01, 102B.01, and 102C.01.

CONSUMER

 “Consumers” include persons who have applied for, are eligible for, are enrolled in, or who have received publicly funded mental health services from the NSMHA service network.  The definition of “consumers” also includes parents or legal guardians for children under the age of thirteen, and parents or legal guardians who are involved in the treatment plan for children 13 and older.

Family members or other interested parties can also utilize this process.  An authorization will be needed from the consumer to share Protected Health Information to the family member or other interested party.  Throughout the policy, the term “consumer” will be used to describe the above groups.

COMPLAINT

A complaint is a verbal or written statement by a consumer that expresses dissatisfaction with some aspect of services covered under the NSMHA PHP Program Agreement, including Service Provider, Primary Care Provider, Provider Network, or Contractor.

Complaints may involve dissatisfaction with service determinations or the initial appeal of any denial, termination, suspension, or reduction of services to include the following actions:

1. The denial or limited authorization of a requested service, including type of service,
2. The reduction, suspension or termination of a previously authorized service,
3. The denial in whole or in part, of payment for a service,
4. The failure to furnish or arrange for a service or provide payment for a service in a timely manner.

GRIEVANCE and APPEAL

A grievance is a written request by a consumer that a complaint be heard and ruled upon by the North Sound Mental Health Administration (NSMHA), usually undertaken after attempted resolution of a complaint fails.

An appeal is a kind of grievance that involves a written request to the NSMHA to appeal service determinations or any denial, termination, suspension, or reduction of services to include the following actions:

1. The denial or limited authorization of a requested service, including type of service,
2. The reduction, suspension or termination of a previously authorized service,
3. The denial in whole or in part, of payment for a service,
4. The failure to furnish or arrange for a service or provide payment for a service in a timely manner.

FAIR HEARING

A Fair Hearing is a hearing conducted through the auspices of the state Office of Administrative Hearings in accordance with WAC 388-02. The term “administrative hearing” is synonymous with fair hearing.

PROVIDER

A provider is any NSMHA contracted service provider.

PROVIDER NETWORK

Refers to the NSMHA contracted provider network’s highest level of administration

DAY

Throughout this policy, the word “day” is defined as a calendar day, unless otherwise specified.

REFERENCES and ADDITIONAL REQUIREMENTS

45 CFR Health Insurance Portability and Accountability Act (HIPAA), Washington Administrative Code (WAC) 388-865-0250, 388-865-0255, 388-865-0340, 388-865-0410, and 388-02. Code of Federal Regulations (CFR) 42 CFR 434.32, 42 CFR 434.32 (b), The Medicaid Waiver and renewal, and the RSN PHP Program Agreement between The State of Washington Department of Social and Health Services (DSHS) and the North Sound Mental Health Administration (NSMHA) or their successors.

The North Sound Mental Health Administration, providers, and provider networks shall comply with all requirements outlined in the North Sound Policy and in references cited above.  The providers and provider networks Complaint and Grievance Policies will be congruent with the NSMHA Policy. 

The providers, provider networks, and ombuds will comply with methods to collect information for quality improvement efforts and to assist the NSMHA in complying with reporting requirements.  The provider networks, providers and ombuds will submit semi-annual reports in compliance with NSMHA and MHD timelines using attachment A or its successors.  

Consumers shall receive, upon request, written recipient information and/or documentation.  The NSMHA, providers, provider networks, or Ombuds shall not charge for the first 100 pages of copying, and may charge a maximum of ten cents per page thereafter. Additional administrative costs such as staff time in preparation of copies or supervision of the record review are prohibited.

Full records of complaints and grievances will be kept for six years after completion of the process in confidential files separate from clinical records.  These records will not be disclosed without the consumer’s written authorization, except as necessary to resolve the grievance or to DSHS if a fair hearing or disenrollment is requested. Complaint and grievance records maintained by the NSMHA are included in our defined designated record set.

PRO-102A.01   INITIATING AND RESPONDING TO COMPLAINTS

This procedure outlines the process for complaints that involve;

1. Services provided by direct service providers,
2. Services provided directly by provider networks or
3. Services provided directly by the NSMHA.

A. For complaints that involve direct service providers:

PRO-102B.01 INITIATING AND RESPONDING TO GRIEVANCES AND APPEALS

PRO-102C.01 INITIATING AND RESPONDING TO REQUESTS FOR FAIR HEARING

Consumers are encouraged to pursue grievances and appeals through the NSMHA complaint and grievance policy prior to filing a fair hearing. A consumer may file an administrative hearing (fair hearing) with The Department of Social and Health Services (DSHS) without first accessing the NSMHA grievance policy.  Consumers have the right to use the DSHS pre hearing and administrative hearing processes described in chapter 388-02 Washington Administrative Code (WAC). Consumers have this right when:

1. The consumer believes there has been a violation of DSHS rule,
2. The NSMHA did not provide a written response within thirty days from the date a written request was received, or
3. The NSMHA, DSHS, or a provider denies service. In cases of disenrollment the enrollee must first utilize the NSMHA complaint and grievance policy.

1. Consumers may be responsible for payment of costs of services in the event that an administrative fair hearing upholds the NSMHA’s action.

2. The provider or provider network will be responsible to pay for benefits provided during an appeal if the administrative hearing upholds the appellant’s grievance.