Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

5.2.1 Introduction
A complaint is defined as an expression of dissatisfaction about any matter other than an action (see definition for “action”). For appeals of actions, see Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons. Possible subjects for complaints include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee or failure to respect the enrollee’s rights.

All persons enrolled in the ADHS/DBHS behavioral health system have access to the same complaint process for expression of dissatisfaction with any aspect of their care. Persons seeking or receiving behavioral health services should always be encouraged to resolve issues at the lowest possible level, yet it is equally important that persons understand that a formal complaint process is also available when needed.

The intent of this section is to present information for behavioral health providers describing the member complaint process. Although the T/RBHAs and ADHS/DBHS are directly responsible for processing all member complaints, it is important for behavioral health providers to understand how a complaint can be filed, reviewed and resolved to the satisfaction of the behavioral health recipient. Behavioral health providers’ responsibilities include educating persons about the complaint process and assisting persons to negotiate the necessary steps to file a complaint.

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5.2.2 References
The following citations can serve as additional resources for this content area:

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5.2.3 Scope
To whom does this apply?

This applies to all persons who are:

  • Seeking behavioral health services through the ADHS/DBHS behavioral health system; or
  • Enrolled with the ADHS/DBHS behavioral health system.

5.2.4 Definitions
Action

Complaint

Health Care Professional

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5.2.5 Did you know?

  • All T/RBHAs are required to staff a customer services manager who is responsible to coordinate communications with eligible and enrolled persons and acts as, or coordinates with advocates, behavioral health providers and others to resolve issues.
  • The ADHS/DBHS and T/RBHA complaint process must:
    • Educate and notify persons about their rights and the process for filing complaints in a manner that is understandable.
    • Resolve complaints in an expeditious and equitable manner and with due regard for the dignity and rights of all persons.
    • Maintain confidentiality and privacy of complaint matters and records at all times.
    • Communicate, as appropriate, timely information on matters and decisions related to the complaint to affected parties.
    • Involve the active cooperation and participation as deemed appropriate of providers with a direct interest in the matter under review.
    • Provide education and training to T/RBHA and provider staff regarding member rights and the complaint process.
    • Track the types and volume of complaints in order to identify potential deficiencies in the delivery system for which corrective action plans can be developed.

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5.2.6 Objectives
To ensure that all persons seeking or receiving behavioral health services have access to a complaint process that fairly and efficiently resolves identified issues.

5.2.7 Procedures

5.2.7-A. Complaint process
Persons enrolled in, or seeking services through, the ADHS/DBHS behavioral health system must file complaints directly with their respective T/RBHA. Member complaints are considered to be any expression by a person of dissatisfaction about any aspect of their care other than the appeal of actions.

Who can file a complaint?
A person enrolled in, or seeking services through the ADHS/DBHS behavioral health system and/or the person’s legal or authorized representative or a provider on behalf of an enrollee at the RBHA’s discretion may file complaints either orally or in writing.

Where must complaints be directed?

  • For oral complaints: Call the Gila River RBHA at this toll free telephone number: 1-888-484-8526.
  • To submit a written complaint: Mail the complaint to the Gila River RBHA Director at the Hu Hu Kam Memorial Hospital, P.O. Box 38, Sacaton, AZ 85247.

How long does the T/RBHA have to resolve a complaint?
T/RBHAs are required to dispose of each complaint and provide oral or written notice as expeditiously as the health condition requires, however, within a timeframe that does not exceed 90 days from the day the T/RBHA receives the complaint, unless an extension is in effect.

Who makes decisions regarding a complaint?
The T/RBHA must ensure that the individuals who make decisions regarding complaints are not involved in any previous level of review or decision-making. Individuals must be health care professionals (see definition) with the appropriate clinical expertise in treating the behavioral health recipient’s behavioral health condition when making a decision regarding:

  • A complaint related to the denial of expedited resolution of an appeal; or
  • Complaints involving clinical issues.

What is the role of behavioral health providers?
The T/RBHA and contracted providers must be available to assist a person in the filing of a complaint and must not retaliate against any persons who file such complaints. Behavioral health providers are also expected to cooperate and participate as requested by the T/RBHA in the resolution of the complaints.

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5.2 Member Complaints
Last Revised: 05/19/2004
Effective Date: 08/01/2004

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