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5.2.1
Introduction
A complaint is defined as an expression of dissatisfaction with any aspect of member care,
other than an action (see definition for “action”). Issues involving an action are subject
to appeal, see Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title
XXI Eligible Persons. For persons determined to have a Serious Mental Illness (SMI)
appealing a decision regarding SMI eligibility, or Non-TXIX/XXI behavioral health recipients
appealing the need for a covered service, see
Section 5.5 Notice and Appeal Requirements
(SMI and Non-SMI/Non-Title XIX/XXI). 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.
For allegations of rights violations involving persons determined to have a Serious Mental
Illness see PM 5.3 Grievance and Requests for Investigation for Persons Determined to have a
Serious Mental Illness. While any behavioral health recipient can file a complaint, the SMI
grievance/request for investigation process is available only to persons determined to have a
Serious Mental Illness.
All persons
enrolled in, or seeking services from, 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 are encouraged to resolve issues at
the lowest possible level, but are not required to do so before utilizing the T/RBHA complaint,
SMI grievance, or appeal processes. Issues that are handled through the complaint resolution
process may still be managed through applicable grievance and appeal processes in the event
they remain unresolved.
The intent of
this section is to present information for behavioral health providers
describing the member complaint process. Although the T/RBHAs 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, appeal, and SMI grievance processes and assisting persons to negotiate the necessary steps to
make 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
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, internal staff resources, 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 appeals and SMI grievance/investigations in a manner that is understandable, including providing interpreter services and toll-free numbe
- Handle any complaints which involve potential fraud or abuse in accordance with applicable agency reporting requirements;
- Promptly identify and resolve
complaints in the most expeditious and equitable manner 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, information on matters and decisions
related to the complaint to affected parties, in a timely
manner.
- 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, including the obligation to report suspected right’s violations of persons determined to have a Serious Mental Illness pursuant to 9 A.A.C. 21-403(C);..
- Track
the types and volume of complaints, (regardless of whom within the organization receives the complaint or whether the complaint is received orally or in writing), in order to identify potential
deficiencies in the delivery system for which corrective action
plans can be developed.
- Refrain from referring complainants to AHCCCS Administration for issues related to the behavioral health delivery system.
5.2.5
Definitions
Action
Appeal
Behavioral Health Professional
Complaint
Grievance or Request for Investigation
Serious Mental Illness (SMI)
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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 in a timely manner.
5.2.7
Procedures
5.2.7-A.
Complaint process
Who can
file a complaint?
- A complaint may be filed by persons enrolled in, or seeking services through the ADHS/DBHS
behavioral health system, a person’s family member, legal guardian, and/or a behavioral health provider.
- Complaints may be filed orally or in writing.
Where must
complaints be directed?
Each T/RBHA is directly responsible for the complaint process and may not delegate this function to a behavioral health provider.
Complaints may be filed directly with the person’s respective T/RBHA, as identified below, or initiated with the ADHS/DBHS Customer Service Unit at (602) 364-4558.
- 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 85147.
All complaints must be acknowledged. Complaints filed orally shall be considered acknowledged at the time of filing. Written complaints must be acknowledged to the complainant within 5 working days of receipt by the T/RBHA.
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 the issue or behavioral 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 needs to be in the complaint record?
At a minimum, the complaint record must include the following documentation:
- The date the complaint was made;
- The behavioral health recipient’s first and last name;
- Title XIX/XXI eligibility status;
- The behavioral health enrollment category: SMI, GMH, Child/Adolescent, Substance Abuse treatment, not enrolled;
- The name of the person making the complaint;
- A description of the complaint;
- Any identified communication needs;
- That the complaint was acknowledged to the originator of the concern and when;
- All steps utilized during the investigation of the complaint and of the resolution;
- Steps taken to assist in ensuring immediate health care needs are met;
- That the resolution was communicated to affected parties, in accordance with confidentiality requirements, and when;
- Implemented corrective action plan(s) or action(s) taken to resolve the concern(s);
- Supporting evidence that the resolution was implemented; and
- Evidence that identified issues were referred, as indicated, to the appropriate committees, departments, and regulatory agencies.
Complaint records must be maintained for a minimum of six years from the date of resolution or disposition.
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: 01/15/2010
Effective Date: 01/15/2010
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