Billing Manual for Community Care Network Providers

An explanation of the grievance process is included in the Member Handbook. A copyof the same information is provided to the Independent Enrollment Assistance Project(IEAP). The IEAP receives new information regarding the grievance procedure as theseprocedures are updated. Community Care will provide training on the grievanceprocedures to the IEAP as requested.Staff education regarding grievance policies and procedures is included in the StaffTraining Plan. Adequate staffing is available to handle the processing of grievances.Denials, Grievances, and Continuation of ServicesWhen a request to continue a non-urgent service that a member receives ispresented to Community Care, Community Care must make its medical necessitydecision within two business days of receipt of sufficient information to reasonablybe able to make that decision.If the decision is to deny (total denial, partial denial of duration or volume,substitution of another service) the service, Community Care must provide themember advance notice of the effective date of that decision. Under normalcircumstances, the member must have 10 calendar days advance notice. (Forexample, if the decision is to reduce a request to continue a service and the decisionis made and the member and provider are informed via letter on November 1, theeffective date of the decision would need to be no sooner than November 11).If the service duration is so short that a 10 day advance notice is not possible, e.g.,Acute Inpatient Mental Health Treatment, the member must receive the notice inadvance of the effective date of the denial. In addition, the notice must provide themember time (at least one calendar day) to file a grievance or request a Departmentof Public Welfare (DPW) Fair Hearing before the effective date of the denial.If the member files a First Level Grievance before the effective date of the servicedenial, services must continue until the outcome of that grievance is conveyed andthe member is provided an opportunity to request further review or until theprescription runs out, whichever is the shorter time period. If the member requests aDPW Fair Hearing before the effective date of the service denial, services mustcontinue until the outcome of the DPW Fair Hearing is conveyed to the member oruntil the prescription runs out, whichever is the shorter time period.If the member files a Second Level Grievance before the effective date of the FirstLevel Grievance decision, services must continue until the outcome of the SecondLevel Grievance is conveyed and the member is provided an opportunity to requestan External Grievance or a DPW Fair Hearing or until the prescription runs out,whichever is the shorter time period. If the member requests a DPW Fair Hearingbefore the effective date of the First Level Grievance decision, services mustcontinue until the outcome of the DPW Fair Hearing is conveyed to the member oruntil the prescription runs out, whichever is the shorter time period.If the member files an External Grievance before the effective date of the SecondLevel Grievance decision, services must continue until the outcome of that grievanceis conveyed and the member is provided an opportunity to request further review orCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 45