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Complaints and Grievances Click on the questions to see the answers or
scroll down.
If you are unhappy with CBHNP or your Provider or you do not agree with a decision CBHNP made about your care, you can do something about it. You can file a complaint. If CBHNP decides that a service you or your Provider asked for is not medically necessary you can file a grievance. You can call or write CBHNP to find out what you can do.
Staff is available to tell you what your rights are and what actions you can
take if you are unhappy with your care or your Provider or if you are
dissatisfied with a decision CBHNP made.
If you would like additional information, keep reading for a more detailed explanation about complaints, grievances and fair hearings. If you need any of this explained in more detail, or if you have any questions about any of this information, call CBHNP Member Services Department for your area and let us know how we can help you! What is a complaint and how do I file a complaint?
You file a complaint when you are unhappy with CBHNP or your Provider or you do
not agree with a decision made by CBHNP.
These are some examples of a complaint:
CBHNP’s
Providers must provide services within one hour for emergencies, within 24
hours for urgent situations, and within 7 days for routine appointments and
specialty referrals. If a treatment plan is approved, services must be provided
according to the prescribed treatment plan.
What should I do if I have a complaint? First Level Complaint To file a complaint, you can:
This is called a first level complaint. When should I file a first level complaint? You must file a complaint within 45 days of getting a letter telling you that:
You must file a complaint within 45 days of the date you should have received a service if your Provider did not give you the service. You may file all other complaints at any time. What happens after I file a first level complaint?
CBHNP will send you a letter to let you know we received your complaint.
The letter will tell you about the first level complaint process. You may ask CBHNP to see any information we have about your complaint. You may also send information that may help with your complaint to CBHNP. If you filed a complaint because of one of the reasons listed below, you can be included in the first level complaint review. You must call CBHNP within 10 days of the date on the letter to tell us that you want to be included.
You can come to our offices or be included by phone. You do not have to attend if you do not want to. If you do not attend, it will not affect our decision. One or more CBHNP staff who has not been involved in the issue you filed your complaint about will make a decision on your complaint. Your complaint will be decided no more than 30 days after we received it. A letter will be mailed to you no more than 5 business days after CBHNP makes its decision. This letter will tell you the reason for the decision. It will also tell you how to file a second level complaint if you don’t like the decision. How do I continue to get services during my complaint? What
to do to continue getting services:
If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a complaint that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made. Second Level Complaint
If you are not happy with CBHNP’s first level complaint
decision, you may file a second level complaint with CBHNP.
When should I file a second level complaint?
You must file your second level complaint within 45 days of
the date you get the first level complaint decision letter. Use the same
address or phone number you used to file your first level complaint.
What happens after I file a second level complaint?
CBHNP will send you a letter to let you know we received your
complaint. The letter will tell you about the second level complaint process.
You may ask CBHNP to see any information we have about your
complaint. You may also send information that may help with your complaint to
CBHNP.
You can come to a meeting of the second level complaint
committee or be included by phone. CBHNP will contact you to ask if you want to
come to the meeting. You don’t have to attend if you do not want to. If you do
not attend, it will not affect our decision.
The second level complaint review committee will have three
or more people on it. At least one CBHNP Member will be on the committee. The
Members of the committee will not have been involved in the issue you filed
your complaint about. The committee will make a decision no more than 30 days
from the date CBHNP received your second level complaint.
A letter will be mailed to you within 5 business days after
the committee makes its decision. This letter will tell you the reason for the
decision. It will also tell you how to ask for an external complaint review if
you don’t like the decision.
What
to do to continue getting services:
If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a second level complaint that is hand-delivered or postmarked within 10 days of the date on the first level complaint decision letter, the services will continue until a decision is made. External Complaint Review
If you are not happy with CBHNP’s second level complaint
decision, you may ask for a review of your complaint by the Department of
Health or the Insurance Department. The Department of Health handles complaints
that involve the way a Provider gives care or services. The Insurance
Department reviews complaints that involve CBHNP’s policies and procedures.
You must ask for an external review within 15 days of the
date you receive the second level complaint decision letter. If you ask,
the Department of Health will help you put your complaint in writing.
You must send your request for external review in writing to
either:
If you send your request for external review to the wrong department, it will be sent to the correct department. The Department of Health or the Insurance Department will get your file from CBHNP. You may also send them any other information that may help with the external review of your complaint. You may be represented by an attorney or another person during the external review. A decision letter will be sent to you after the decision is made. This letter will tell you the reason for the decision and what you can do if you don’t like the decision. What to do to continue getting services:
If you have been receiving services that are being reduced,
changed, or stopped because they are not covered services for you and you file
a request for an external complaint review that is hand-delivered or postmarked
within 10 days of the date on the second level complaint decision letter, the
services will continue until a decision is made.
You file a grievance when you disagree with CBHNP’s decision
that a service requested by you or your Provider is not medically necessary.
You can file a grievance if CBHNP does any one of these
things:
First Level Grievance
If CBHNP does not completely approve a service for you, we
will tell you in a letter. The letter will tell you how to file a grievance.
You have 45 days from the date you receive this letter to file a grievance.
To file a grievance, you can:
Your Provider can file a grievance for you if you give the Provider your consent in writing to do so. NOTE: If your Provider files a grievance for you, you cannot file a separate grievance on your own. What happens after I file a first level grievance?
CBHNP will send you a letter to let you know we received your
grievance. The letter will tell you about the first level grievance process.
You may ask CBHNP to see any information we have about your grievance. You may
also send information that may help with your grievance to CBHNP.
If you want to be included in the first level grievance
review, you must call us within 10 days of the date on the letter we sent you
to let you know we received your grievance. You can come to our offices or be
included by phone. You don’t have to attend if you do not want to. If you do
not attend, it will not affect our decision.
A committee of one or more CBHNP staff, including a doctor or
licensed psychologist who has not been involved in the issue you filed your
grievance about, will make a decision about your first level grievance. Your
grievance will be decided no more than 30 days after we received it.
A letter will be mailed to you no more than 5 business days
after CBHNP makes its decision. This letter will tell you the reason for the
decision. It will also tell you how to file a second level grievance if you
don’t like the decision.
What
to do to continue getting services:
If you have been receiving services that are being reduced, changed, or stopped, and you file a grievance that is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that the services you have been receiving are being reduced, changed, or stopped, the services will continue until a decision is made. Second Level Grievance
If you are not happy with CBHNP’s first level grievance
decision, you may file a second level grievance with CBHNP.
When should I file a second level grievance?
You must file your second level grievance within 45 days of
the date you get the first level grievance decision letter. Use the same
address or phone number you used to file your first level grievance.
What happens after I file a second level grievance?
CBHNP will send you a letter to let you know we received your
grievance. The letter will tell you about the second level grievance process.
You may ask CBHNP to see any information we have about your grievance. You may
also send information that may help with your grievance to CBHNP.
You can come to a meeting of the second level grievance
committee or be included by phone. CBHNP will contact you to ask if you want to
come to the meeting. You don’t have to attend if you do not want to. If you do
not attend, it will not affect our decision.
The second level grievance review committee will have three
or more people on it. At least one CBHNP Member and a doctor or licensed
psychologist will be on the committee. The Members of the committee will not
have been involved in the issue you filed your grievance about. The committee
will make a decision no more than 30 days from the date CBHNP received your
second level grievance.
A letter will be mailed to you within 5 business days
after the committee makes its decision. This letter will tell you the reason
for the decision. It will also tell you how to ask for an external grievance
review if you don’t like the decision.
What
to do to continue getting services:
If you have been receiving services that are being reduced, changed, or stopped, and you file a second level grievance that is hand-delivered or postmarked within 10 days of the date on the first level grievance decision letter, the services will continue until a decision is made.
External Grievance Review
If you are not happy with CBHNP’s second level grievance
decision, you can ask for an external grievance review. You must call or send a
letter to CBHNP asking for an external grievance review within 15 days of the
date you received the second level grievance decision letter. Use the same
address and phone number you used to file your first level grievance. We will
then send your request to the Department of Health. The Department of Health
will notify you of the external grievance reviewer’s name, address and phone
number. You will also be given information about the external review process.
CBHNP will send your grievance file to the reviewer. You may
provide additional information that may help with the external review of your
grievance, to the reviewer, within 15 days of filing the request for an
external grievance review.
You will receive a decision letter within 60 days of the date
you asked for an external grievance review. This letter will tell you the
reason for the decision and what you can do if you don’t like the decision.
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