UCS CLIENT GRIEVANCE AND APPEALS
PURPOSE: To establish a formal mechanism for soliciting and responding to complaints, grievances and/or appeals on the part of clients or other interested parties, to utilize such information in the quality improvement efforts of the organization and to ensure compliance with the Vermont Agency of Human Services (AHS) Grievance and Appeals process.
POLICY: It is the policy of United Community Services that any grievance or appeal regarding services and/or support raised by a client, parent, family member, guardian, or a person acting on behalf of the client, who does so with his/her express permission, will be given due consideration.
DEFINITIONS (as defined by the Medicaid Program Grievance and Appeals manual):
An action is an occurrence of one or more of the following by United Counseling Service (UCS) for which an internal appeal may be requested.
a.) Adverse Benefit Determination means any of the following:
- Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements of medical necessity, appropriateness, setting, or effectiveness of a covered service,
- Reduction, suspension, or termination of a previously authorized service,
- Denial, in whole or in part, of payment for a service,
- Failure to provide services in a timely manner, as defined by the Agency of Human Services,
- Failure to act within timeframes regarding standard resolution of grievances and appeals,
- Denial of a beneficiary’s request to obtain services outside of a network,
- Denial of a beneficiary’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other beneficiary liabilities
b.) Internal Appeal is a request for an internal review of an action by United Counseling Service (UCS) of an adverse benefit determination.
c.) Designated Agency/Specialized Service Agency (DA/SSA) means an agency designated or deemed by the Department of Mental Health or the Department of Disabilities, Aging and Independent Living to provide and administer services, including services authorization decisions, for beneficiaries with mental health needs and/or developmental disabilities.
d.) ACO means Accountable Care Organization
e.) Authorized Representative means an individual, either appointed by a member or authorized under state or other applicable law, to act on behalf of the member in obtaining a determination or in dealing with any of the levels of the appeal or grievance process. Unless otherwise stated in the rule, the designated representative has all of the rights and responsibilities of a member in obtaining a determination or in dealing with any of the levels of the appeals process.
f.) Expedited Internal Appeal means an appeal in an emergent situation in which taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.
g.) Fair Hearing means an external appeal that is filed with the Human Services Board, and whose procedures are specified in rules separate from the UCS process.
h.) Grievance is an expression of dissatisfaction about any matter that is not an adverse benefit determination, including a member’s right to dispute an extension of time proposed by UCS and the denial of a request for an expedited appeal. Possible subjects for grievance include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member’s rights. If a grievance is not acted upon within the timeframes specified, the member may ask for a fair hearing under the definition above of an action as being “failure to act in a timely manner when required by state rule.”
i.) Medicaid Program means (1) DVHA in its managed care function of administering services, including service authorization decisions, under the Global Commitment to Health Waiver (“the Waiver”), (2) a State department of AHS (i.e., Department of Children and Families; Department of Disabilities, Aging, and Independent Living; Department of Health; and Department of Mental Health) with which DVHA enters into an agreement delegating its managed care functions including providing and administering services such as service authorization decisions, under the Waiver, (3) a Designated Agency or a Specialized Service Agency to the extent that it carries out managed care functions under the Waiver, including providing and administering services such as service authorization decisions, based upon an agreement with a State department of AHS, and (4) any subcontractor performing service authorization decisions on behalf of a State department of AHS.
j.) Network means the providers who are enrolled in the Vermont Medicaid program and who provide services on an ongoing basis to beneficiaries.
k.) Provider means a person, facility, institution, partnership, or corporation licensed, certified or authorized by law to provide services to a beneficiary.
l.) Service means a benefit (1) covered under the Global Commitment to Health Waiver, (2) included in the State Medicaid Plan, (3) authorized by state rule or other law, (4) required by federal law, or (5) identified in the Intergovernmental Agreement between DVHA and AHS for the administration and operation of the Global Commitment to Health Waiver.
AHS Departments: Department of Mental Health (DMH); Department of Disabilities, Aging and Independent Living (DAIL); Division of Disability and Aging Services (DDAS); Department of Health, Division of Alcohol and Substance Abuse (ADAP); Department of Health, Vision of Children with Special Needs (CSHN), Department of Vermont Health Access (OVHA).
Notices of full state procedures can be found in the Grievance and Appeal Manuals published by: DMH for mental health programs; DAIL for developmental services and ADAP for substance abuse programs. The Grievance and Appeals Coordinator will provide copies upon request.
PROCEDURE: A person receiving or participating in services and/or programs will be oriented to, and receive a copy of, the Agency’s Grievance & Appeal policy and procedure upon enrollment in a program.
A grievance may be expressed orally or in writing. A member or designated representative may file a grievance at any time. Staff members will assist a member if the member or his representative requests such assistance. This includes but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have TTY/TDD and interpreter capability. Clients or their representatives (i.e., a person receiving services, their family member, or other person acting on their behalf) do not have to request a written response from the agency to have their concern addressed as a formal grievance.
Members may grieve a matter that is not an adverse benefit determination including denial of a request for an expedited appeal, an extension of time by UCS for decision of a service authorization or resolving an internal appeal, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, and the failure to respect a beneficiary’s rights.
The agency will not require that grievances be put in writing before considering them formal grievances. The agency will make forms available for this purpose, but the member is not required to complete the form. Agency staff members will assist a member if the member or their representative requests assistance in filing a grievance. UCS will train staff in the practices and procedures to promote prompt informal and formal resolution of disagreements.
A person receiving services, their family member, or other person acting on their behalf, having a grievance or appeal shall be offered a Grievance and Appeal Form to complete and/or explain the grievance or appeal to the person’s primary UCS therapist, case manager or service provider who will assist with, or complete, the Grievance and Appeal Form. The primary therapist/case manager/service provider shall report the grievance or appeal to the UCS Grievance and Appeals Coordinator, either directly or through the related Division Director, using the Grievance and Appeal Form. The original form will be forwarded to the Grievance and Appeal Coordinator. The Division Director will work with the Grievance and Appeal Coordinator to review/investigate all grievances and appeals from the initial filing through resolution.
UCS shall provide the member, free of charge, with all the information in its possession or control relevant to the grievance process and the subjects of the grievance, including the members case record, including medical records and other records and documents related to the grievance, and other information relevant to members grievance including relevant policies and procedures.
Alleged Harm: If a grievance is composed of a clear report of alleged physical harm or potential harm, UCS will immediately investigate or refer to the appropriate investigatory body (fraud, malpractice, professional regulation board, Adult Protective Services, etc.).
Written Acknowledgment: All grievances and appeals require a written acknowledgment to be sent to the client and/or the person filing the grievance or appeal within five (5) calendar days of receipt of the grievance or appeal. If the issue is resolved within five days, the resolution or outcome notice will be sufficient and no written acknowledgment will be required. All UCS grievances and appeals will be logged into the Department of Vermont Health Access’s (DVHA) Grievance and Appeal database. UCS Complaints will be logged into an in-house database.
Withdrawal of Grievances: Members or their designated representatives may withdraw grievances orally or in writing at any time. If a grievance is withdrawn orally, the withdrawal will be acknowledged by UCS in writing within five (5) days.
Disposition: All grievances shall be addressed within 30 days of receipt. The UCS Grievance and Appeals Coordinator must provide the member with written notice of the disposition. The written notice shall include a brief summary of the grievance, the basis or rationale for the decision in sufficient detail for the member to understand the decision, and the disposition. If the response is adverse to the member, the notice must also inform the member of his or her right to initiate a grievance review with the State as well as information on how to initiate such review. If UCS does not act upon the grievance within the timeframe for the resolution, the member may request an internal appeal pursuant to the definition of adverse benefit determination.
a.) Filing of Appeals: Members may file appeals orally or in writing for any adverse benefit determination. There is no right to appeal matters where a federal or state law requiring change has adversely affected some or all members. Providers and representatives of the member may initiate appeals only after a clear determination that the third party’s involvement is being initiated at the member’s request, except that providers may not request the services be continued pending appeal. Appeals of adverse benefit determination must be filed with UCS within sixty (60) days of the date the agency’s notice of adverse benefit determination. The parties to an internal appeal are the beneficiary or their representative, or the legal representative of a deceased beneficiary’s estate. UCS will give members reasonable assistance in completing forms or other steps to initiate and participate in the internal appeals process. Assistance auxiliary aids and services upon request as also noted above. Members may also contact the Office of Health Care Advocate at 1-800-917-7787 for help with this process or decision making about the process.
b.) Written Acknowledgement of the appeal shall be mailed within five (5) days of receipt of appeal by the agency.
c.) Withdrawal of Appeals may be done orally or in writing at any time by members or their representatives.
d.) Member Participation in Appeals: The member, their authorized representative, or their provider, if requested by the provider has the right to participate in person, by phone, or in writing in the meeting in which UCS is considering the issue that is the subject of the appeal. This may include the right to present evidence, testimony and legal arguments. Upon request and prior to the appeal meeting, the agency shall provide timely copies of information relevant to the appeals process and the subject of the appeal, at no cost to the member. UCS shall inform the member of the scheduled appeal meeting and reschedule to accommodate individuals wishing to participate. If a meeting cannot be scheduled within the timeframe for resolving the appeal, the agency may make a decision that resolves the appeal without a meeting with the member, or their representatives.
e.) Appeals Reviewer: The UCS staff member responsible for hearing the appeal shall not have been involved in any previous level of review or decision making, not be a subordinate of any such individual, and shall have appropriate clinical expertise of member conditions or illness when deciding an appeal of a denial of medical necessity.
Resolution: UCS shall act promptly and in good faith to obtain necessary information to resolve the appeal. The internal review shall be completed, appeals shall be decided, and written notice sent to the member within thirty (30) days of receipt of the appeal. The individual/representative or UCS may request an extension of up to 14 days if that extra time is in the best interests of the individual. The maximum total time period for the resolution of an appeals, including any extension requested either by the member or the Medicaid Program, is 44 days. If a meeting cannot be scheduled within these timeframes, a decision will be rendered by the Medicaid Program without a meeting with the member, the designated representative, or treating provider.
Expedited Internal Appeals Request: Expedited appeals may be requested in emergent situations in which the member or the treating provider (in making the request on the member’s behalf or supporting the member’s request) indicates that taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. Requests for expedited internal appeals may be made orally or in writing with the Medicaid Program for any adverse benefit determination subject to appeal. No punitive action may be made against a provider who requests or supports an expedited resolution.
If the request for an expedited appeal is denied because it does not meet the criteria, the Medicaid Program will inform the member that the request does not meet the criteria for expedited resolution and that the appeal will be processed within the standard 30 -day time frame. An oral notice of the denial of the request for an expedited appeal must be promptly communicated (within 2 days) to the member and followed up within 2 days of the oral notification with a written notice.
If the expedited appeal request meets the criteria for such appeals, it must be resolved within 72 hours. If an expedited appeal cannot be resolved within 72 hours, the time frame may be extended up to an additional 14 days by request of the member, or by the Medicaid Program if the extension is in the best interest of the member. If the extension is at the request of the Medicaid Program, it must give the member written notice of the reason for the delay. An oral notice of the expedited appeal decision must be promptly communicated (within 2 days) to the member and followed up within 2 days of the oral notification with a written notice. The written notice for any expedited appeal determination shall include a brief summary of the appeal, the resolution, the basis for the resolution, and the member’s right to request a fair hearing if not already requested.
Finally, clients shall be advised of their right to representation or the assistance of an advocate at any stage of the grievance and appeal procedure. They will also be assured of the confidentiality of the proceedings and that no retribution of any kind will result from filing a grievance or an appeal.
Fair Hearing: This is a process whereby the individual/representative making an appeal and UCS, working with DMH and the DMH Legal Unit, each presents their side of the situation to the Human Services Board. A request for fair hearing by the Human Services Board (HSB) must be filed no later than 30 days after receipt of the adverse appeal decision or within 90 days of the original action.
Complaint Procedures of Other State or Federal Programs: Additional processes shall be followed as outlined by state or federal bodies not specified in this policy but whose regulations require a specific complaint procedure. When applicable to a UCS program, such details will be included in the division Operations Manual; an example being the Civil Rights Requirements in Child Nutrition Programs as governed by the Vermont Agency of Education and the U.S. Department of Agriculture.