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5.5.1
Introduction
This section applies to notice and appeal requirements for:
- Persons who
have been determined to have a serious mental illness (SMI);
- Persons
who are applying for an SMI eligibility determination;
- Behavioral
health recipients who do not have a serious mental illness and
who are not Title XIX or Title XXI eligible; and
- Persons who
are Title XIX/XXI eligible, who do not have a Serious Mental
Illness and who are not covered under Section 5.1, Notice
Requirements and Appeal Process for Title XIX and Title XXI
Eligible Persons.
The notice requirements
and the appeal process for persons who are Title XIX/XXI eligible
are described in Section 5.1, Notice Requirements and Appeal Process
for Title XIX and Title XXI Eligible Persons.
Persons who
are applying for or have been determined to have a serious mental
illness must be provided notice under certain circumstances. Notice
allows a behavioral health recipient to exercise their right to
appeal a decision or can inform persons of their rights. This section
describes the circumstances when notice must be provided to persons
who are applying for or have been determined to have a serious mental
illness.
Persons who
are applying for or have been determined to have a serious mental
illness can appeal certain decisions. These include, but are not
limited to:
- Decisions
regarding an SMI eligibility determination;
- Decisions
regarding the need for, the timely provision of, or the continuation
of behavioral health services; and
- Decisions
regarding charges or co-payments for behavioral health services.
Persons who
do not have a serious mental illness and who are not Title XIX or
Title XXI eligible do not receive notices, but can appeal decisions
related to the provision of Non-Title XIX/XXI, Non-SMI funded behavioral
health services.
Persons who
are Title XIX/XXI eligible, who do not have a Serious Mental Illness
do not receive notices, but can appeal decisions related to the
provision of behavioral health services that fall outside those
covered under Section 5.1, Notice Requirements and Appeal Process
for Title XIX and Title XXI Eligible Persons and appeals process for
a person with a Serious Mental Illness under section 5.5.7-E of this
policy.
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5.5.2
References
The following citations can serve as additional resources for this
content area:
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5.5.3
Scope
To whom does this apply?
This section
applies to:
- Persons
who have been determined to have a serious mental illness (SMI);
- Persons
who are applying for an SMI eligibility determination;
- Behavioral
health recipients who do not have a serious mental illness and
who are not Title XIX or Title XXI eligible; and
- Behavioral
health recipients who are Title XIX/XXI eligible who do not have a
Serious Mental Illness and who are not covered under Section 5.1,
Notice Requirements and Appeals Process for Title XIX and Title
XXI Eligible Persons.
5.5.4
Definitions
Action
Appeal
Complaint
Denial
Limited Authorization
Qualified
Clinician
PASRR
Prior
Authorization
Reduction
of Service
Suspension
of Service
Termination
of Service
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5.5.5
Objectives
The objectives of this section are to ensure:
Persons applying for or who have been determined to have a serious
mental illness are provided required notices, which:
- Are timely;
- Explain
the action to be taken and the appeal process available to the
person or custodial/legal guardian; and
- Are written
in a manner that is clear and easily understood by the person;
and
Persons applying
for or who have been determined to have a serious mental illness
and persons who do not have a serious mental illness and who are
not Title XIX or Title XXI eligible have access to an appeals process
that fairly and efficiently resolves identified issues.
Persons who
are Title XIX/XXI eligible, who do not have a Serious Mental
Illness, and are not covered under Section 5.1, Notice Requirements
and Appeals Process for Title XIX and Title XXI Eligible Persons
have access to an appeals process that fairly and efficiently
resolves identified issues.
5.5.6
Did you know…?
- Each RBHA
is responsible for processing appeals and may not delegate this
responsibility to any other entity.
- Although
the RBHAs and ADHS/DBHS are directly responsible for processing
all member appeals, it is important for behavioral health providers
to be aware of the fundamental aspects of the appeal process and
to offer behavioral health recipients assistance when requested
or necessary.
- Persons
determined to have a serious mental illness, or others acting
on their behalf, may also file grievances and requests for investigation
under specified conditions (see Section 5.3, Grievance and Request
for Investigation for Persons Determined to have a Serious Mental
Illness).
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5.5.7
Procedures
5.5.7-A.
General requirements for notice and appeals
Behavioral health providers must be aware of general requirements
guiding notice and appeal rights for the populations covered in
this section. Behavioral health providers may have direct responsibility
for designated functions (i.e., sending notice) as determined by
the RBHA and/or may be asked to provide assistance to persons who
are exercising their rights to appeal.
How is time
computed?
In computing any time prescribed or allowed in this section, the
period begins the day after the act, event or decision occurs and
includes all calendar days and the final day of the period. If the
final day of the period is a weekend or legal holiday, the period
is extended until the end of the next day that is not a weekend
or a legal holiday; however, if the period of time is not designated
as calendar days and is less than 11 days, then intermediate Saturdays,
Sundays and legal holidays must not be included in the computation.
Language,
format and comprehensive clinical record requirements
Notice and related forms must be available in each prevalent, non-English
language spoken in the RBHA’s geographic service area. As
designated by the RBHA, behavioral health providers must provide
free oral interpretation services to all persons who speak non-English
languages for purposes of explaining the appeal process and/or information
contained in the notice.
Notice and other
written documents pertaining to the appeal process must be available
in alternative formats, such as Braille, large font or enhanced
audio and must take into consideration any special communication
needs of the person applying for or receiving behavioral health
services.
The provision
of notice must be documented by placing a copy of the notice in
the person’s comprehensive clinical record.
Delivery
of notices and appeal decisions
All notices and appeal decisions must be personally delivered or
mailed by certified mail to the person applying for or receiving
behavioral health services, and/or their legal representative, at
their last known residence or place of business. In the event that it may be unsafe to
contact the person at his or her home, or those cases in which the
person has requested that mail not be sent to his or her home, alternative
methods identified by the person for communicating notices must
be utilized.
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5.5.7-B.
Notice requirements for persons applying for or who have been determined
to have a serious mental illness
Under what circumstances does a notice have to be provided?
For actions (see definition) related to Title XIX/XXI covered services,
see Section 5.1, Notice Requirements and Appeal Process for Title
XIX and Title XXI Eligible Persons.
The following
provisions apply to notice requirements for persons determined to
have a serious mental illness and for persons for which an SMI eligibility
determination is being considered:
Persons who
are applying for an SMI eligibility determination must receive
PM
Attachment 5.5.1, Notice of SMI Grievance and Appeal
Procedure, at the time of application.
PM
Form 5.5.1, Notice of Decision and Right to Appeal
must be provided to persons determined to have a serious mental
illness or to persons applying for SMI services when:
- Initial eligibility
for SMI services is determined. The notice must be sent within
two days of the eligibility determination;
- A decision
is made regarding fees or waivers;
- The assessment
report, individual service plan or individual treatment and discharge
plan is developed, provided or reviewed;
- An outcome
of a grievance of rights violation occurs;
- A decision
is made to modify the individual service plan, reduce, suspend or
terminate a service that does not require prior authorization or
is a service funded through Non-Title XIX funds. In this case,
notice must be provided at least 30 days prior to the effective
date unless the person consents to the change or a qualified
clinician determines that the action is necessary to avoid a
serious or immediate threat to the health or safety of the person
receiving services or others;
- A decision
is made that the person is no longer eligible for SMI services;
and
- A PASRR
determination in the context of either a preadmission screening or
an annual resident review, which adversely affects the person.
Other notices
that must be provided to persons determined to have a serious mental
illness
The following additional notices must be provided to persons determined
to have a serious mental illness or persons applying for SMI services:
- Notice of
legal rights for persons with serious mental illness (see ADHS
Form MH-211) at the time of admission to a behavioral health provider
agency for evaluation or treatment. The person receiving this
notice must acknowledge in writing the receipt of the notice and
the behavioral health provider must retain the acknowledgement
in the person’s comprehensive clinical record. All behavioral
health providers must post ADHS Form MH-211, “Notice of
Legal Rights for Persons with Serious Mental Illness”, in
both English and Spanish, so that it is readily visible to behavioral
health recipients and visitors;
- Notice of
discrimination prohibited (ADHS Form MH-209), available in English
or Spanish, at the time of discharge from the behavioral health
provider agency.
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5.5.7-C.
Notice requirements for Non-Title XIX/XXI/ Non-SMI populations
Behavioral health recipients who do not have a serious mental illness
and who are not Title XIX or Title XXI eligible are not required
to receive notice under any circumstance.
Who is responsible
for providing the notice?
Following a decision requiring notice to a behavioral health recipient,
the Gila River RBHA or ADHS must ensure the communication of a notice
to the person.
ADHS/DBHS sends
notices to persons determined to have a serious mental illness who
are enrolled with a Tribal RBHA when making a decision on behalf
of the Tribal RBHA.
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5.5.7-D.
Filing an appeal
Appeals that are related to a RBHA or one of their contracted behavioral
health providers’ decisions must be filed with the RBHA. Appeals
that are related to a Tribal RBHA or one of their contracted behavioral
health providers’ decisions and appeals that relate to PASRR
decisions are filed with and processed by
the ADHS/DBHS Office of Grievance and Appeals.
Title XIX/XXI
eligible persons applying for or who have been determined to have
a serious mental illness and who are appealing an action (see definition)
affecting Title XIX/XXI covered services may elect to use either
the Title XIX/XXI appeal process (see Section 5.1, Notice Requirements
and Appeal Process for Title XIX and Title XXI Eligible Persons)
or the appeal process for persons determined to have a serious mental
illness described within subsection 5.5.6-D.
What kinds
of appeals exist?
There are two appeal processes applicable to this section:
- Appeals of
persons applying for or determined to have a serious mental illness;
and
- Appeals
for other covered service related issues.
Who can
file an appeal?
The following persons and entities may file an appeal:
- An adult
applying for or receiving behavioral health services, their legal
guardian, guardian ad litem, designated representative or attorney;
- A legal
guardian or parent who is the legal custodian of a person under
the age of 18 years;
- A court
appointed guardian ad litem or an attorney of a person under the
age of 18 years;
- A state or
governmental agency which acquires behavioral health services
through an ISA/IGA with ADHS, but which does not have legal custody
or control of the person shall have appeal rights to the extent
specified in the ISA/IGA between the agency and the ADHS; and
- A provider,
acting on the behavioral health recipient’s behalf and with
the written authorization of the person.
What are
the timeframes for filing an appeal?
Appeals must be filed orally or in writing with the responsible
RBHA, or ADHS/DBHS when required, within 60 days from the date of
the decision being appealed. Late appeals must be accepted upon
showing good cause.
Where must
appeals be directed?
- For oral
appeals to ADHS/DBHS: Call ADHS/DBHS at this toll free number-1-800-421-2124
or (602) 364-4574 within Maricopa County.
- To submit
a written appeal to ADHS/DBHS: Mail the appeal to 150 North 18th
Avenue, Suite 210, Phoenix, Arizona 85007.
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5.5.7-E.
Appeal process for persons applying for or who have been determined
to have a serious mental illness
An appeal may be filed concerning one or more of the following:
- Decisions
regarding the person’s SMI eligibility determination;
- Sufficiency
or appropriateness of the assessment;
- Long-term
view, service goals, objectives or timelines stated in the Individual
Service Plan (ISP) or Inpatient Treatment and Discharge Plan (ITDP);
- Recommended
services identified in the assessment report, ISP or ITDP;
- Actual services
to be provided, as described in the ISP, plan for interim services
or ITDP;
- Access to
or prompt provision of services;
- Findings
of the clinical team with regard to the person’s competency,
capacity to make decisions, need for guardianship or other protective
services or need for special assistance;
- Denial of
a request for a review of, the outcome of, a review of, a modification
to or failure to modify or termination of an ISP, ITDP or portion
of an ISP or ITDP;
- Application
of the procedures and timeframes for developing the ISP or ITDP;
- Implementation
of the ISP or ITDP;
- Decision
to provide service planning, including the provision of assessment
or case management services to a person who is refusing such services,
or a decision not to provide such services to the person;
- Decisions
regarding a person’s fee assessment or the denial of a request
for a waiver of fees;
- Denial of
payment of a claim;
- Failure
of the RBHA or ADHS/DBHS to act within the timeframes regarding
an appeal; and
- A PASRR
determination, in the context of either a preadmission screening
or an annual resident review, which adversely affects the person.
In addition,
allegations of rights violations made by persons determined to have
a serious mental illness are addressed through the SMI grievance
and request for investigation process described in Section 5.3,
SMI Grievances and Requests for Investigation for Persons Determined
to have a Serious Mental Illness (SMI).
Expedited
appeals
A person, or a provider on the person’s behalf, may request
an expedited appeal for the termination of crisis or emergency services,
the denial of admission to or the termination of a continuation
of inpatient services or for good cause.
Continuation
of services for appeals involving persons determined to have a serious
mental illness
For persons determined to have a serious mental illness, the person’s
behavioral health services will continue while an appeal of a modification
to or termination of a covered behavioral health service is pending
unless:
- A qualified
clinician determines the modification or termination is necessary
to avoid a serious or immediate threat to the health or safety
of the person or another individual; or
- The person
or, if applicable, the person’s guardian, agrees in writing
to the modification or termination.
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5.5.7-F.
General Appeals for Non-Title XIX/XXI/ Non-SMI populations
Based on available funding, a person who is Non-Title XIX/XXI and
Non-SMI may file an appeal of a decision that is related to a determination
of need for covered behavioral health service that falls outside
those covered under Provider Manual Section 5.1, Notice Requirements
and Appeal Process for Title XIX and Title XXI Eligible Persons and
appeals process for persons with a Serious Mental Illness under
section 5.5.7-E of this policy (e.g. modification to previously authorized
services for a non-Title XIX/XXI eligible person).
In these circumstances,
there is no continuation of services available during the appeal
process.
5.5.7-G.
Behavioral health provider responsibilities
While providers are not directly responsible for the resolution
of appeals, they are required to actively participate in the process
as follows:
- Provide
information deemed to be necessary by the RBHA, ADHS/DBHS or the
Office of Administrative Hearings (e.g., documents and other evidence);
and
- Cooperate
and participate as necessary throughout the appeal process.
Behavioral health
providers must be available to assist a person in the filing of
an appeal. For persons determined to have a serious mental illness,
the Office of Human Rights is also available to assist the person
in filing as well as resolving the appeal.
Behavioral health
providers must not retaliate against any persons who file appeals
or interfere with a person’s right to file an appeal. Additionally,
no punitive action will be taken against a behavioral health provider
who supports a person’s appeal.
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5.5
Notice and Appeal
Requirements (SMI and Non-SMI/Non-Title XIX/XXI)
Last Revised: 02/02/2006
Effective Date: 10/01/2006 |
