What if I have problems with services or my rights are not respected?

At NBHP we care about you and the quality of services that you get. We work hard to give you the best care. We are always trying to improve how we serve you. If you have problems with your services or if you disagree with a clinical decision, we need to hear from you.

Medicaid has a process for you to file a grievance (complaint) about your services. Medicaid also has a process for you to appeal a denial or reduction in service. Our Office of Member and Family Affairs staff can help you file a complaint or appeal. You can also contact our Service Center to start an appeal process.

Terms (Definitions)

Action: an action is when NBHP:

• Denies or limits all or part of a requested treatment;
• Reduces, changes or ends treatment that was already approved;
• Denies payment in whole or in part for a service;
• Does not provide services in a timely manner;
• Fails to act within approved time frames for grievances and appeals; or
• Denies a request to obtain treatment outside the network in rural areas.

Appeal: An Appeal is when a Member disagrees with an Action by NBHP and asks for a review of the Action.

Designated Client Representative (DCR): This is a person whom you name to file a grievance or appeal on your behalf. This person can be one of your service providers, including your doctor, a friend or a family member.

Grievance: A Grievance is when a member complains about his or her mental health services, a provider or staff. Members can file a Grievance about any dissatisfaction with a service or staff person.

Notice of Action: This is a letter which explains the Action that NBHP is taking and your Appeal rights.

State Fair Hearing Process: This is a hearing before a State administrative law judge and is available for Appeals only.

How do I file a grievance (complaint)?

If you are comfortable doing so, it is a good idea to talk directly with your provider or a supervisor so that problems can be fixed quickly. If you don’t want to do that, or if you have tried that and are still not satisfied, there are many ways you can file a grievance:

• Contact the Member or Family Advocate at your mental health center: They are listed in Appendix A of this handbook.
• Contact the Office of Member and Family Affairs at 970-347-2367 or 1-888-296-5827.
• Contact the Ombudsman for Medicaid Managed Care at 303-830-3560, 1-877-435-7123, TTY 1-888-876-8864. They will help you file a grievance with the BHO.

You may ask a family member, friend or provider to file a grievance for you. However, you must make that person your “Designated Client Representative.” This means that you sign a form naming that person as your DCR and also sign a Release of Information for NBHP to share information with that person.

You can file your grievance in person, on the phone, or by letter or grievance form. You must file your grievance within 30 calendar days from when the event happened. You need to tell us your name and the best way to contact you.

After we receive your grievance, we will send you a letter within two (2) working days telling you we received the grievance and asking you to tell us if we understood you correctly.

We will look into your grievance and may call you for more information. If your grievance involves a clinical issue, we will talk to a clinical person who was not previously involved. This process is confidential. You or your family member will not lose your Medicaid benefits for filing a grievance.

Within fifteen (15) working days after we get your grievance, we will mail you a letter with our decision. If you, or we, need more time to get information about your grievance that is in your best interest, we will extend the time for up to fourteen (14) more calendar days. We will send you a letter telling you why and how it is in your best interest to get the information.

The decision letter will explain that if you do if you do not agree with our decision, you can call the Department of Health Care Policy and Financing (HCPF) for a review. To do so, contact:

Medicaid Customer Service at
303-866-3513 (Denver Metro area)
1-800-221-3943 (outside the Metro area)
TTY 303-866-7471

The decision of HCPF will be final.

How do I file an appeal (appeal an action)?

If you disagree with the decision in the notice of action, defined at the beginning of this section on grievances and appeals, you have the right to file an appeal. Staff of Office of Member and Family Affairs can help you in any way you need to file an appeal with NBHP or with the Office of Administrative Courts for a State Fair Hearing.

You must make your appeal within thirty (30) calendar days from when we sent the Notice of Action letter. You can make your appeal in person or by phone, but must follow up in writing. You may ask a family member, friend or provider to appeal for you. However, you must make that person your Designated Client Representative. This means that you sign a form naming that person as your DCR and also sign a Release of Information for NBHP to share information with that person. An expedited (quick) appeal process is available if the standard time for resolving an appeal would cause harm.

What if my treatment was already approved but the BHO now wants to stop my treatment?

This is a special situation. If your treatment has been approved, but NBHP or your provider decides to stop or decrease the service, you must file your appeal within ten (10) calendar days of the day we sent the Notice of Action letter that your treatment will stop (Notice Of Action letter), or ten (10) calendar days from the day when the treatment is scheduled to stop or change, whichever is later.

Who do I call to file an appeal?
There are many ways you can file an appeal.

• Contact the NBHP Care Management Department at 1-800-804-5008 or write them at:

Northeast Behavioral Health Partnership
Care Management Department
7150 Campus Drive, Suite 300
Colorado Springs, CO 80920

• Contact the Ombudsman for Medicaid Managed Care at 303-830-3560, 1-877-435-7123, TTY
  1-888-876-8864. They will help you file your appeal.
• Contact the Ombudsman for Medicaid Managed Care at 303-830-3560, 1-877-435-7123, TTY
  1-888-876-8864. They will help you file your appeal.
• Contact the State Office of Administrative Courts directly. You do not have to file with NBHP first, but you must let NBHP know you have contacted the Office of Administrative Courts. Their
  contact information is:

Office of Administrative Courts
633 17th Street Suite 1300
Denver, CO 80202
303-866-2000
Fax: 303-866-5909

If you appeal to NBHP we will send you a letter to let you know we got your appeal. We will do this within two (2) working days. The letter will also tell you more about the appeal process including the fact that you can provide evidence of fact or law in person.

We will make a decision and send you a letter with the decision within ten (10) working days. We will also try to call you first on the telephone. If you think you may be harmed by waiting the 10 working days for either type of appeal, you can ask for an expedited or quick appeal. For an expedited appeal, we will make the decision and send you the decision letter (and call you on the phone first, if possible) within three (3) calendar days of the date we received the expedited appeal.

If you need more time to get information to help your appeal, or if we need more time, we will extend the time of the decision letter for up to fourteen (14) more calendar days. We will send you a letter telling why more time is needed and why it is in your best interest for us to get the information. It will tell you when to expect the decision.

What if I disagree with NBHP’s decision about my appeal?

If you are not satisfied with our decision, you may appeal to the Office of Administrative Courts and ask for a State Fair Hearing. However, you must do this within thirty (30) calendar days from the date NBHP sent the Notice of Action for a denial of a requested service. You must appeal within ten (10) calendar days about a previously authorized service. We encourage you to file with the Office of Administrative Courts at the same time that you file your appeal with NBHP. That way, you will not lose your right to a State Fair Hearing. You can provide evidence of fact or law and have someone represent you at the hearing.

If you ask for an appeal or a State Fair Hearing, the service you requested will continue if:

• You or your provider files the appeal within the required time frames;
• You ask for your benefits to continue;
• The services you are asking to continue were authorized by NBHP; and
• The current service authorization has not expired.
  During the time you are appealing, your requested services will continue for a limited time. The services
  will continue only until one of the following things happens:
• You withdraw your appeal;
• 10 days pass after we mail the notice of action, and you have not asked for a State Fair Hearing;
• You have asked for a State Fair Hearing, and their decision is to stop your services; or
• The original authorization for your service has expired.
  Important Note: If your appeal is denied at the State Fair Hearing level, you may have to pay for the cost
  of services you received while your appeal was being reviewed.

Ombudsman for Medicaid Managed Care

The Ombudsman is an advocacy organization independent of NBHP. They can help you file a grievance or appeal, if you want. The Ombudsman for Medicaid Managed Care can also help you with other mental health quality issues. There is no cost to you to use the Ombudsman. Any Medicaid member who lives in Colorado can use them.

Their contact information is:

Ombudsman for Medicaid Managed Care
1-877-435-7123 outside of Denver
303-830-3560 in the Denver Metro area.
TTY 1-888-876-8864 for hearing impaired