Current through Register 2024 Notice Reg. No. 52, December 27, 2024
(a) An MHP shall develop problem resolution
processes that enable a beneficiary to resolve a problem or concern about any
issue related to the MHP's performance of its duties under this Chapter,
including the delivery of specialty mental health services.
(b) The MHP's beneficiary problem resolution
processes shall include:
(1) A grievance
process;
(2) An appeal process;
and
(3) An expedited appeal
process.
(c) For the
grievance, appeal, and expedited appeal processes, found in Sections
1850.206,
1850.207 and
1850.208 respectively, the MHP
shall ensure:
(1) That each beneficiary has
adequate information about the MHP's processes by taking at least the following
actions:
(A) Including information describing
the grievance, appeal, and expedited appeal processes in the MHP's beneficiary
booklet and providing the beneficiary booklet to beneficiaries as described in
Section 1810.360.
(B) Posting notices explaining grievance,
appeal, and expedited appeal process procedures in locations at all MHP
provider sites sufficient to ensure that the information is readily available
to both beneficiaries and provider staff. The posted notice shall also explain
the availability of fair hearings after the exhaustion of an appeal or
expedited appeal process, including information that a fair hearing may be
requested whether or not the beneficiary has received a notice of action
pursuant to Section
1850.210. For the purposes of this
Section, an MHP provider site means any office or facility owned or operated by
the MHP or a provider contracting with the MHP at which beneficiaries may
obtain specialty mental health services.
(C) Making forms that may be used to file
grievances, appeals, and expedited appeals, and self addressed envelopes
available for beneficiaries to pick up at all MHP provider sites without having
to make a verbal or written request to anyone.
(2) That a beneficiary may authorize another
person to act on the beneficiary's behalf. The beneficiary may select a
provider as his or her representative in the appeal or expedited appeal
process.
(3) That a beneficiary's
legal representative may use the grievance, appeal, or expedited appeal
processes on the beneficiary's behalf.
(4) That an MHP staff person or other
individual is identified by the MHP as having responsibility for assisting a
beneficiary, at the beneficiary's request, with these processes, including
assistance in writing the grievance, appeal, or expedited appeal. If the
individual identified by the MHP is the person providing specialty mental
health services to the beneficiary requesting assistance, the MHP shall
identify another individual to assist that beneficiary.
(5) That a beneficiary is not subject to
discrimination or any other penalty for filing a grievance, appeal, or
expedited appeal.
(6) That
procedures for the processes maintain the confidentiality of
beneficiaries.
(7) That a procedure
is included by which issues identified as a result of the grievance, appeal or
expedited appeal processes are transmitted to the MHP's Quality Improvement
Committee, the MHP's administration or another appropriate body within the MHP
for consideration in the MHP's Quality Improvement Program as required by
Section 1810.440(a)(5).
(8) That the individuals making the decision
on the grievance, appeal, or expedited appeal were not involved in any previous
review or decision-making on the issue presented in the respective problem
resolution process.
(9) That the
individual making the decision on the grievance, appeal, or expedited appeal
has the appropriate clinical expertise as determined by the MHP to treat the
beneficiary's condition, if the grievance is regarding the denial of a request
for an expedited appeal or if the grievance, appeal, or expedited appeal is
about clinical issues.
(d) For the grievance, appeal, and expedited
appeal processes found in Sections
1850.206,
1850.207, and
1850.208, the MHP shall:
(1) Maintain a grievance and appeal log and
record grievances, appeals, and expedited appeals in the log within one working
day of the date of receipt of the grievance or appeal. The log entry shall
include but not be limited to the name of the beneficiary, the date of receipt
of the grievance, appeal, or expedited appeal, and the nature of the
problem.
(2) Record in the
grievance and appeal log or another central location determined by the MHP the
final dispositions of grievances, appeals, and expedited appeals, including the
date the decision is sent to the beneficiary, or document the reason(s) that
there has not been final disposition of the grievance, appeal, or expedited
appeal.
(3) Provide a staff person
or other individual with responsibility to provide information on request by
the beneficiary or an appropriate representative regarding the status of the
beneficiary's grievance, appeal, or expedited appeal.
(4) Acknowledge the receipt of each
grievance, appeal, and expedited appeal to the beneficiary in
writing.
(5) Identify the roles and
responsibilities of the MHP, the provider, and the beneficiary.
(6) Notify those providers cited by the
beneficiary or otherwise involved in the grievance, appeal, or expedited appeal
of the final disposition of the beneficiary's grievance, appeal, or expedited
appeal.
(e) No provision
of an MHP's beneficiary problem resolution processes shall be construed to
replace or conflict with the duties of county patients' rights advocates as
described in Welfare and Institutions Code, Section
5520.
1. New
subchapter 5 and section filed 10-31-97 as an emergency; operative 11-1-97
(Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL
by 3-2-98 or emergency language will be repealed by operation of law on the
following day.
2. New subchapter 5 and section refiled 3-2-98 as an
emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance
must be transmitted to OAL by 6-30-98 or emergency language will be repealed by
operation of law on the following day.
3. New subchapter 5 and
section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No.
25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a
Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency
language will be repealed by operation of law on the following
day.
4. Editorial correction of HISTORY 3 (Register 98, No.
39).
5. Editorial correction extending Certificate of Compliance
date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item
4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of
law, emergency regulations adopted pursuant to Welfare and Institutions Code
section
14680
to implement the second phase of mental health managed care as provided in this
part shall remain in effect until permanent regulations are adopted, or June
30, 2006, whichever occurs first.
6. Editorial correction of HISTORY
5 (Register 2000, No. 42).
7. Editorial correction of HISTORY 5, new
article 1 heading and repealer and new section filed 5-19-2006; operative
6-18-2006 (Register 2006, No. 20).
Note: Authority cited: Section
14680,
Welfare and Institutions Code. Reference: Sections
5520
and
14684,
Welfare and Institutions Code; and Title 42, Code of Federal Regulations, Part
438, Subpart F.
