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Complaints and Grievances Community Behavioral HealthCare Network of Pennsylvania (CBHNP) has established a fair and uniform process for Members to resolve complaint and grievances at the lowest administrative level consistent with the HealthChoices Requirements for Behavioral Health Managed Care Organizations.
Frequently Asked Questions
Q: Can a provider file a grievance?
A: Yes. As long as there is Member consent. A provider must have the Authorization for Representation form signed by the Member and sent to CBHNP before CBHNP can open and process the grievance. This form is posted in the C&G section. Q: Can a provider file a complaint against another provider?
A: Yes. However, CBHNP encourages resolution of provider issues before contacting CBHNP. If a provider feels they have exhausted all options of working with another provider, they can call CBHNP to file a provider to provider complaint. Q: Can the Member continue services during a grievance, and will the provider claims be paid for these services?
A: Yes, as long as the services that were requested are a continuation of the previously authorized service. CBHNP uses a service notification form that is generated and faxed to the provider to verify what services can be continued and for a specific timeframe. This notification is also sent to internal departments to generate an authorization for continuation rights for that specific period of time for claim payment. Q: Can a provider submit additional information to CBHNP during the grievance process?
A: Yes. It is within the Member’s rights of the grievance process and any party on behalf of the Member to submit additional documentation as part of the grievance review. However, if a provider is submitting an addendum regarding the current services that are being reviewed in the grievance, this will be used as additional documentation only for the grievance. A separate MNC review will not occur for that packet. If new services are being requested, then this is a separate MNC review. Q: What happens if the grievance process continues to the next authorization period?
A: If the grievance process is still pending when a new re-authorization request is to be submitted, the provider will submit the new authorization per CBHNPs normal process and regulations for submitting reauthorization requests for the particular level of care. Q: Who facilitates Level II grievances in the Capital Area?
CABHC will begin facilitating Level II grievances for the Capital Area only (Cumberland, Dauphin, Lancaster, Lebanon, and Perry Counties) in June of 2007. This will not change the filing or meeting scheduling process, you will still contact CBHNP. The only change is the CABHC staff will be facilitating the actual Level II meeting. |
