United Behavioral Health Grievance System: Consumer Right to a Fair Hearing Policy Identifier/Number: CR-02D Annual Review Completed Date: February 2016 Policy Category: Government Pierce Regional Support Network Approved by: Bea Dixon, Executive Director Applicable Lines of Business: Medicaid Entity/Plan: Optum Pierce Behavioral Health Organization Signature: State: Pierce County, Washington Policy Statement and Purpose Optum Pierce Behavioral Health Organization (BHO) and its contracted behavioral health care providers encourage consumers and/or family members to utilize all levels of the Optum Pierce BHO Grievance System (grievances and appeals). Enrollees must exhaust the BHO s Grievance and Appeal process prior to filing a request for a Fair Hearing with the Washington State Office of Administrative Hearings (OAH).The Optum Pierce BHO and its contracted behavioral health care providers share information with BHO-funded individuals about their rights to a State Fair Hearing and the procedures for requesting a hearing as described in this policy. To outline the state Administrative or Fair Hearing process and requirements. Policy Audience and Applicability This policy is applicable to the Optum Pierce BHO and benefits administered through the Washington State Department of Social and Health Services (DSHS) current Prepaid Inpatient Health Plan (PIHP). Policy Definitions For Title XIX Individuals, Grievance means any expression of dissatisfaction about any matter other than an Action as defined in Optum Pierce BHO s policy titled, CR-02C: Grievance System Medicaid Enrollee s Notice of Action. For Statefunded individuals, grievances are expressions of dissatisfaction about any matter. The term grievance also refers to the overall system that includes grievances and appeals handled through Optum Pierce BHO and the State administrative Fair Hearing process. Grievances may include, but are not limited to, problems with quality of care or services provided and aspects of interpersonal relationships, such as rudeness. Grievances may be initiated either orally or with a signed and dated written request. Optum is responsible for adhering to all applicable state and/or federal laws governing activities within the scope of this policy, including the Mental Health Parity and Addiction Equity Act (MHPAEA ) and the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements, as well as the applicable requirements, standards and regulations as set forth by the Employee Retirement Income Security Act (ERISA), the Center for Medicare and Medicaid Services (CMS), the Department of Labor (DoL), and any applicable accrediting organizations. This document is proprietary and is intended for internal use only. This document is not to be released outside the organization without appropriate authorization.
Action: A decision by the Optum Pierce BHO regarding: The denial or limited authorization of a requested service, including the type or level of service; The reduction, suspension, or termination of a previously authorized service; The denial, in whole or in part, of payment for a service; The failure to provide services in a timely manner as defined by the Department of Social & Health Services Mental Health Division (DSHS); or The failure of Optum Pierce BHO to act within the timeframes outlined in 42 CFR 438.52(b) (2) (ii). Appeal: A request for review of an Action as described above. Individual: A person who has applied for, is eligible for, or who has received behavioral health services. For a child, under the age of 13, or for a child age 13 or older whose parents or legal guardians are involved in the treatment plan, the definition of individual includes parents or legal guardians. Continuation of Services: Services continue to be provided with no change in type or frequency during the appeal process. Denial: The decision to not authorize Title XIX-covered behavioral health services that meet the DSHS Access to Care Standards or the decision not to authorize Title XIX- covered behavioral health services due to lack of medical necessity. Expedited Grievance: A request for a more immediate response to a grievance than occurs through the standard procedure. Expedited grievances may be pursued at the provider or BHO level. Fair or Administrative Hearing: A hearing before the Washington State Office of Administrative Hearings. Grievance for Title XIX Individuals: An expression of dissatisfaction about any matter other than an Action as defined in Optum Pierce BHO s policy titled, CR-02C: Grievance System Medicaid Enrollee s Notice of Action. Grievances for State-funded consumers are expressions of dissatisfaction about any matter. The term also refers to the overall system that includes grievances and appeals handled through Optum Pierce BHO and the State administrative Fair Hearing process. Grievances may include, but are not limited to, problems with quality of care or services provided and aspects of interpersonal relationships such as rudeness. A grievance may be pursued at the provider level or BHO level. Grievances may be initiated either orally or in writing. Medicaid Enrollee: An individual who is a member of the Medicaid or Title XIX managed health care plan. Prior Authorization: A determination made that an applicable Title XIX-covered service is medically necessary. Title XIX services may require authorization prior to the DSHS mandate or prior to the designation of Optum as the Pierce BHO. Qualified Clinician: A behavioral health professional as defined in WAC 388-877-0200 and any successors, which includes but is not limited to: A psychiatrist, psychologist, psychiatric advanced registered nurse practitioner (ARNP), or social worker as defined in RCW 71.05 and 72.34; or A person with a master s degree or further advanced degree in counseling or one of the social sciences who has at least two years of experience in direct Page 2 of 6
treatment of persons with behavioral illness or emotional disturbance, that was gained under the supervision of a behavioral health professional. A person credentialed by the department of health as a chemical dependency professional (CDP) with primary responsibility for implementing an individualized service plan for substance use disorder services. Reduction: A decision to decrease the frequency and/or duration of an on-going service. A reduction does not include a planned change in service frequency or duration that is initially identified in the person s individual service plan and agreed to in writing by the individual receiving services or his/her legal guardian. Suspension: A decision to temporarily stop providing a previously authorized Title XIX- covered behavioral health service. Termination: A decision to stop providing a previously authorized Title XIXcovered behavioral health service. Termination does not include the end of a specific treatment program with an established end date initially identified in the person s individual service plan and agreed to in writing by the individual receiving services or their legal guardian. Title XIX Service: Behavioral health services covered by Title XIX funding. Policy Provisions 1. Right to Request a Fair Hearing 1.1. Individuals and their representatives have the right to request the Department of Social and Health Services (DSHS) pre-hearing and administrative hearing processes as described in WAC 388-02 when: 1.1.1. An Individual believes there has been a violation of the DSHS rules; 1.1.2. The Optum Pierce BHO or contracted behavioral health care providers violate timeframe requirements for a grievance or the Optum Pierce BHO violates timeframe requirements for an appeal or expedited appeal; 1.1.3. A Medicaid enrollee does not receive a favorable disposition from an appeal to the Pierce BHO; and/or 1.1.4. An Individual does not receive a favorable disposition of a grievance to the Optum Pierce BHO. 1.2. The Individual requesting review of an Action: 1.2.1. Must file an Appeal and receive a Notice of Resolution from the BHO before requesting a Fair Hearing; and 1.2.2. May not file a Grievance with the BHA or the BHO for the same issue as the Appeal once an Appeal has been filed. 1.3. Medicaid enrollees or their representative may also request an expedited Fair Hearing when the enrollee or representative believes that taking the time for standard resolution would jeopardize the enrollee s ability to maintain or regain maximum functioning. 2. Assistance with Fair Hearings 2.1. Optum Pierce BHO and its behavioral health care providers provide assistance to Individuals in pursuing Fair Hearings. Ombuds Services are also available, at no cost, to investigate, advocate, and assist Individuals throughout the Fair Hearing process. 2.2. An Individual may have a representative who acts on his/her behalf in requesting a Page 3 of 6
Fair Hearing. An Individual may also have representatives of his/her choice involved in the process. There is to be no retaliation against a consumer who requests a Fair Hearing. Individuals may contact the Optum Pierce BHO if they have concerns about retaliation. 3. Timelines to File a Fair Hearing 3.1. If a Medicaid enrollee does not receive favorable disposition of a grievance or appeal by the Optum Pierce BHO, she or he may request a Fair Hearing. The request for a Fair Hearing must be filed within 10 calendar days from the date on the Notice of Resolution if the Individual is asking that services be continued pending the outcome of the hearing, or 3.2. Within 90 calendar days from the date of the adverse ruling for appeals if no continuation of services is requested. 3.3. Individuals must exhaust all levels of the Optum Pierce BHO grievance or appeals process before requesting a Fair Hearing. 3.4. If no written notice of resolution or disposition was received, the Individual may still request an administrative (Fair) hearing. 3.5. If an individual believes there has been a violation of the DSHS rules or that the Pierce BHO or behavioral health care providers have violated certain timeline requirements, he or she may request a Fair Hearing at any time. 4. Where to Request a Fair Hearing 4.1. Individuals may request a Fair Hearing with the Office of Administrative Hearings (OAH) at 1-800-583-8271. The OAH is part of Washington State government. 4.2. Individuals may also contact the Optum Pierce BHO or the Ombuds Services for assistance in requesting a Fair Hearing. 5. Continuation of Benefits/Services during the Fair Hearing Process 5.1. Individuals may request that their previously authorized services or benefits continue or be reinstated during the State administrative or Fair Hearing process. 5.2. If a Medicaid enrollee believes that a DSHS rule or timeline requirement has been broken and requests a Fair Hearing prior to utilizing the Optum Pierce BHO appeal or grievance process, the Optum Pierce BHO is to continue or reinstate previously authorized services pending a Fair Hearing at the enrollee s request if all the following apply: 5.2.1. The enrollee requests an administrative hearing within the required timeframes described in this policy; 5.2.2. The request involves an appeal concerning the termination, suspension, or reduction of a previously authorized course of treatment; 5.2.3. The services were requested by an authorized community behavioral health agency; 5.2.4. The period covered by the original authorization has not expired at the time of the request for continuation of benefits; and 5.2.5. The enrollee requests continuation of benefits. 5.3. When the above criteria are met, the BHO continues the Individual s behavioral health treatment services during the administrative hearing process until one of the following occurs: 5.3.1. The Individual withdraws the hearing request; Page 4 of 6
5.3.2. The administrative law judge issues a hearing decision adverse to the Individual 5.3.3. The period covered by the original authorization of behavioral health services has expired. 5.4. For State-funded individuals, previously authorized services will continue within available resources. 5.5. Individuals, including Medicaid enrollees, are notified in writing of any circumstances in which the individual may be asked to pay for the cost of those services if the hearing decision upholds the original decision. 6. Reversed Resolutions of Appeals 6.1. If the State Fair Hearing officer reverses a decision to deny, limit, or delay services that were not furnished while an appeal was pending, the Optum Pierce BHO and behavioral health care providers are to authorize or provide the disputed services promptly and as expeditiously as the individual s behavioral health condition requires. 6.2. If the State Fair Hearing Officer reverses a decision to deny authorization of services and the individual received the disputed services while the appeal was pending, the Optum Pierce BHO is to pay for those services. 6.3. If the final resolution of the appeal upholds the Optum Pierce BHO s Action, the Optum Pierce BHO may recover the amount paid for the services provided to the individual while the appeal was pending, to the extent that they were provided solely because of the requirement for continuation of services and in accordance with CFR 41.431.230 (b). 7. Additional Requirements for Fair Hearings 7.1. For Fair Hearings that involve Appeals, parties to the Fair Hearing include the Optum Pierce BHO, the Individual, and the Individual s representative or the representative of a deceased Individual s estate. 7.2. The Optum Pierce BHO, behavioral health agencies, networks, and other contracted individuals and providers are to cooperate with and promptly abide by all administrative hearing procedures and decisions. The Optum Pierce BHO requires this commitment in contracts and monitors this requirement. 8. Record Keeping and Reporting Requirements 8.1. The Optum Pierce BHO maintains records of standard and expedited appeals and reviews the information at least annually as part of the Division of Behavioral Health and Recovery s quality strategy. 8.2. Standard and expedited appeal records are to be kept by the Optum Pierce BHO for a period of 6 years following the date of resolution. These records are to be kept separate from an Individual s clinical records and are not to be disclosed without the Individual s permission, except as necessary to resolve an appeal. 8.3. The Optum Pierce BHO submits a quarterly standard and expedited appeals report to DSHS. Reports include: 8.3.1. The number and nature of standard and expedited appeals; 8.3.2. The timeframes within which they were disposed or resolved; 8.3.3. The nature of the decisions; and 8.3.4. A summary and analysis of the implications of the data, including Page 5 of 6
what measures will be taken to address undesirable trends and patterns. 8.4. The Optum Pierce BHO monitors quality through: 8.4.1. Oversight during the standard and expedited appeals process to ensure that services are provided as required, timelines for decisions are met as required, and retaliation does not occur; 8.4.2. Monthly Optum Pierce BHO data collection of standard and expedited appeals; and 8.4.3. Aggregation of data and trends reported to the Optum Pierce BHO QA/PI Committee for the purposes of quality monitoring and service improvement. Related Policies, Procedures & Materials Pierce Behavioral Health Organization Policy: CR-01 - Consumer Rights and Responsibilities Pierce Behavioral Health Organization Policy: CR-02 - Grievance System - Grievance Process Pierce Behavioral Health Organization Policy: CR-03 - Grievance System Medicaid Enrollee s Right to Appeal Pierce Behavioral Health Organization Policy: CR-04 - Grievance System Medicaid Enrollee s Notice of Action Pierce Behavioral Health Organization Policy: CR-06 - Ombuds Services Attachments N/A Approval History Policy created and effective: 07/2009 Policy and Procedure Committee review and approval: 10/26/2009 Policy and Procedure Committee review and approval: 08/23/2010 Policy and Procedure Committee review and approval: 09/26/2011 Policy and Procedure Committee review and approval: 08/27/2012 Policy and Procedure Committee review and approval: 12/02/2013 Policy and Procedure Committee review and approval: 12/15/2014 Policy and Procedure Committee review and approval: 02/24/2016 Operation Procedures and Standards Committee reviewed and accepted: 01/25/2017 Page 6 of 6