Billing Manual for Community Care Network Providers

Upon request, the member will be assisted, at no cost, by Community Care staff incompleting forms and other procedural steps related to the grievance. The member (ortheir designated representative) is allowed before, or during the grievance process, toexamine their case file, including medical records, upon request to Community Care.Community Care will accept grievances from individuals with disabilities which are inalternative formats including:TTY for telephone inquiries and grievances from members who are hearingimpaired.Braille, tape, computer disk, and other commonly accepted alternative forms ofcommunication.Community Care will provide members with disabilities assistance in presenting theircase at grievance reviews at no cost to the member. This includes:Providing qualified sign language interpreters for members who are severely hearingimpaired.Providing information submitted on behalf of Community Care at the grievancereview in an alternative format accessible to the member filing the grievance. Thealternative format version will be supplied to the member at or before the review, sothe member can discuss and/or refute the content during the review.Providing personal assistance to members with other physical limitations in copyingand presenting documents and other evidence.Once initiated, the subsequent steps of a standard grievance are:A First Level Grievance acknowledgement letter will be sent to the member (or totheir guardian or representative if applicable), with a copy to their treating prescriberand provider within five business days of Community Care’s receipt of the First LevelGrievance.The practitioner, member and/or family member/guardian will be made aware of thedocumentation required for resolution of the grievance. Documentation may includesending copies of part or all of the medical record and/or a written statement fromthe practitioner.The member will be afforded a reasonable opportunity to present evidence, andallegations of fact or law, in person as well as in writing. Community Care will beflexible when scheduling the review to facilitate the member’s attendance. If themember cannot appear in person at the review, an opportunity to communicate withthe First Level Grievance review committee by telephone or videoconference will beprovided.A Community Care professional advisor (a psychiatrist or licensed, doctoralprepared psychologist), who is a health care professional with clinical expertise intreating the member’s condition or disease, and was not involved in the initial denialdetermination, will review the documentation provided.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 47