Billing Manual for Community Care Network Providers

the member or provider for more information to assist in the disposition of thecomplaint. Upon receipt of a request for a Second Level Complaint review, Community Carewill provide the member with written notification regarding the Second LevelComplaint Committee Review procedures and hearing. The member will be notifiedof established protocols for the hearing process, investigation of the complaint, andthe role of the Second Level Complaint Review Committee. These protocols areconsistent with the requirements of the Department of Public Welfare and theDepartment of Health. A hearing of the Second Level Complaint Review Committee will be held within 30days of the receipt of the request for the hearing and will be conducted at a time andplace convenient to the member. The member will be notified in writing of thescheduled hearing at least 15 days in advance and will be invited to appear. Themember may elect not to attend the Second Level Complaint Review Committeehearing at his/her discretion; the hearing will be conducted by the same protocols asif the member were present. The member always has the right to attend and to present the case and has a rightto be assisted/represented by persons of his/her choice. The member may submitwritten material and has a right to question Community Care staff or the providerabout the complaint. The committee may not discuss the case to be reviewed prior to the second levelreview meeting. The committee shall base its decision solely upon the materials andtestimony presented at the review. Formal rules of evidence are inappropriate as this proceeding is envisioned as aninformal attempt to amicably resolve differences. The Second Level Complaint Review Committee is expected to conduct an informaland impartial proceeding using as the basis for their deliberation the written decisionof the First Level Complaint review. Committee members will be clearly identified asto staff and subscriber members. The Committee is to consider this dispute basedsolely on the material and presentations during the hearing. If an attorneyrepresenting the Second Level Complaint Review Committee is present, the attorneywill represent the interest of the impartial committee and not the staff memberinvolved in the dispute. Staff previously involved in the complaint may present andsummarize the decision for the Committee. The Committee will be permitted toquestion Community Care staff and the provider. An audio recording of the Second Level Complaint Review Committee hearing willbe made as required by the Department of Public Welfare and Department ofHealth. Electronic records will be kept for at least three years by the Complaint andGrievance Department. Access to this information will be limited to the director ofcomplaints and grievances, complaint and grievance coordinators, quality managers,Chief Clinical Officer, and Chief Medical Officer, or their designee, and will beavailable for appeal review by the Department of Health or Insurance Department. The Second Level Complaint Review Committee will issue a written decision withinfive business days of the hearing. The notice will contain: (a) an understanding ofthe complaint and pertinent facts; (b) the decision itself, the basis of the decision,and rationale; (c) an explanation of the member’s right to request review by theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 42