Current through Register 2024 Notice Reg. No. 38, September 20, 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.
