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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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