Billing Manual for Community Care Network Providers

Notices must be in alternate formats that allow access for all individuals. The right toa DPW Fair Hearing may be exercised at the same time that the member uses theCommunity Care grievance process or in lieu of Community Care’s grievanceprocess. A copy of the notice must also be sent to the provider who requested theservice being denied.At all phases of Community Care’s grievance process, the member has the right torequest a DPW Fair Hearing from the OMHSAS Division of Grievances and Appeals.A member can appeal the initial determination and/or the results of the First orSecond Level of Grievance decision by Community Care.A member may request a Fair Hearing within 30 days of the date on the initial writtennotice of decision and within 30 days from the date on a complaint or grievancenotice of decision at any level, of any of the following:• The denial, in whole or in part, of payment for a requested service if based onlack of medical necessity.• The denial of a requested service on the basis that the service is not a coveredbenefit.• The denial or issuance of a limited authorization of a requested service, includingthe type or level of service.• The reduction, suspension, or termination or a previously authorized service.• The denial of a requested service but approval of an alternative service.• The failure to provide services in a timely manner, as defined by DPW.• The failure of Community Care to decide a complaint or grievance within thetimeframes specified by DPW.• The retrospective denial of payment because the service(s) was provided by anout of network non-Pennsylvania Medical Assistance participating providerwithout authorization.The request for a fair hearing must include a copy of the written notice of decisionthat is the subject of the request. Requests should be sent to:Department of Public WelfareOffice of Mental Health and Substance Abuse ServicesDivision of Grievance and AppealsBeechmont Building #32P.O. Box 2675Harrisburg, PA 17105-2675A member who files a request for a Fair Hearing to dispute a decision to discontinue,reduce, or change a service that the member has been receiving must continue toreceive the disputed service at the previously authorized level pending resolution ofthe Fair Hearing, if the request for a Fair Hearing is hand delivered or post-markedwithin 10 days of the date of the written notice of decision (within 1 calendar forurgent care decisions).Upon the receipt of the request for a Fair Hearing, the Department’s Bureau ofHearings and Appeals or a designee will schedule a hearing. The member andCommunity Care will receive notification of the hearing date by letter at least 10 daysin advance, or a shorter time if requested by the member. The letter will outline theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 54