1	BEFORE VIEWING THIS TRAINING You only need to take this training if your job is in the list on the Due Process Training Page. Click the “Back arrow” button at the top of this window to return to the Training Page. If your job is not in the list, you must still take the Recipient Rights Annual Update Training and Test, located on the Office of Recipient Rights page of our website If you have questions about whether you need this training, contact the Human Resources or Training Department at your agency.
2	Due Process – Grievance and Appeal Procedures
3	What is Due Process? The right of every person seeking or receiving mental health or developmental disability services from Oakland County Community Mental Health Authority or its contracted agencies. Includes the right to appeal “actions” and to file grievances about other matters of dissatisfaction with treatment
4	Where do these rights come from? US Constitution Social Security Act of 1965 Balanced Budget Act of 1997
5	MEDICAID BASICS A Medicaid card “entitles” a person to services that are medically necessary Medicaid is the payor of last resort
6	MEDICAID BASICS The individual plan of service resulting from person-centered planning must specify for EACH service: Scope Amount Duration Dates when the service begins and ends
7	APPEALS VS. GRIEVANCES What is an appeal? A request for review of a decision to deny, terminate, suspend, or reduce a Medicaid Covered Service. What is a grievance? A request for review about any matter of dissatisfaction other than those issues covered by the appeal process
8	Timeframes to Request Appeal Appeal (other than second opinion)– Fair Hearing 90 days from date of notice Local 45 days from date of notice Before effective date of action to keep services in place Second Opinion Eligibility for services 5 days from 1^st denial Hospitalization 24 hours
9	Fair Hearing Appeal Process A Medicaid beneficiary has the right to request a fair hearing when the PIHP or its contractor takes an “action”, a grievance request is not acted upon within 60 calendar days. The beneficiary does not have to exhaust local appeals before they can request a fair hearing
10	Fair Hearing Process Person must be notified in writing Person’s freedom to make a request for a Fair Hearing may not be limited or interfered with Person has 90 calendar days from the date of the notice to file a request for hearing If FH is requested not more than 12 calendar days from date of notice, person may request services be reinstated/continued until disposition of FH If notice not given, services must be reinstated to pre-action level Expedited hearings are available
11	Local Appeal Process For appeal of an “action” – either Medicaid or non-Medicaid beneficiary Person has 45 calendar days from date of notice to request Local appeal Oral request ok Services may be continued/reinstated if person requests and appeal filed no more than 12 calendar days from date of notice May be done before, at same time, or instead of a Fair Hearing
12	Non-Medicaid Appeals Person without Medicaid can request agency-level review, local appeal, or State-level Alternative Dispute Resolution Must be done sequentially
13	Definition of Action - Services Reduction, suspension, or termination of a previously authorized service Failure to provide services within 14 calendar days of the start date agreed upon during the person-centered planning and as authorized.
14	Definition of Action - Authorizations Denial or limited authorization (less than person requests or less than current authorization) of a requested service, including type or level of service Failure to make a standard authorization decision and provide notice within 14 calendar days from the date of receipt of a standard request for service Failure to make an expedited authorization decision within three (3) working days from the date of receipt of a request for expedited service authorization
15	Definition of Action - Payment The denial, in whole or in part, of payment for a service Notice goes to person, not provider
16	Definition of Action– Appeals and Grievances STANDARD APPEAL - Failure of the PIHP to act within 45 calendar days from the date of a request EXPEDITED APPEAL - Failure of the PIHP to act within 3 working days from the date of a request LOCAL GRIEVANCE/COMPLAINT - Failure of the PIHP to provide disposition and notice within 60 calendar days of the date of the request
17	Expedited Appeal Can be granted if “the time necessary for normal appeal process could seriously jeopardize the person's life or health or ability to attain, maintain, or regain maximum function” Must be completed in 3 days May be requested by the person or the person's provider If the person requests the expedited review, the PIHP determines if the request is warranted If the provider makes request, or supports request, the PIHP must grant the request
18	Adequate Notice A written notice provided to the person at the time of action. Denial of Eligibility Denial of request for new or increased service Limited authorization (time or amount of service) The IPOS must include, or have attached, the adequate notice provisions
19	Advance Notice Written notice Required when an action is being taken to reduce, suspend or terminate services that the person is currently receiving. must be mailed or given to person 12 calendar days before the intended action takes effect.
20	Exceptions to advance notice Notice may be mailed not later than date of action (adequate notice) IF: Death of the person is confirmed The person gives clear written statement they no longer wish service or gives info requiring termination AND indicates they understand that this must be result of giving that information The person is admitted to institution (jail) where they are ineligible under Medicaid for further services The person’s whereabouts are unknown and mail returned with no forwarding address
21	Exceptions, continued Fact is established that person has been accepted for Medicaid services by another local jurisdiction, State, territory or commonwealth A change in the level of medical care is prescribed by the beneficiary’s physician The date of the action will occur in less than 10 calendar days (LTC facility)
22	Authorization Timeframes Initial request or continuation of service – PIHP must provide written authorization decision Within specified timeframes Standard – 14 calendar days Expedited – 3 working days And/or as expeditiously as person's health condition requires May extend up to additional 14 days if person or provider requests or more info needed AND extension is in person's best interest
23	Authorization Extension IF the PIHP extends the timeframe it must: Give the person written notice, no later than the date the current timeframe expires, including: reason for the decision to extend the timeframe and inform the person of the right to file an appeal if they disagree with that decision AND Issue and carry out determination as expeditiously as person’s health condition requires and no later than the date the extension expires
24	Notice Mailing Timeframes At least 12 calendar days before the date of an action to terminate, suspend or reduce previously authorized Medicaid covered service (Advance) Within 14 calendar days of a request for a standard service authorization decision to deny or limit services (Adequate) Within 3 working days of the request for an expedited service authorization decision to deny or limit services (Adequate) At the time of the decision to deny payment for a service (Adequate)
25	Questions? Due Process (248) 858-1262 Customer Services 1-800-341-2003 Recipient Rights 1-877-744-4878
26	TAKE THE DUE PROCESS TEST You have now completed the Due Process Annual Training Update required for persons whose job requires detailed knowledge of Due Process. You must now take the Due Process Test. You may start the test by clicking the “Back” arrow near the top of this window and clicking on “Due Process Test” located near the top of the Due Process Training page. When you complete the test, your answers and scores will be automatically entered into a database. Your employer will receive a printout each month showing who has taken the test, the date they completed it, and their score. This will be the evidence that you have completed the training requirement.