The Massachusetts Behavioral Health Partnership Appeal Process

Transcription

1 The Massachusetts Behavioral Health Partnership Appeal Process The Massachusetts Behavioral Health Partnership (MBHP) is the behavioral health contractor for the MassHealth Behavioral Health Programs Unit. MBHP is responsible for managing mental health and substance abuse treatment provided to you and other MassHealth Members. You have the right to appeal Adverse Actions made by MBHP. Most of the time, Adverse Actions are decisions made by MBHP to approve payment or not approve payment for services that your provider requested for you. These kinds of Adverse Actions happen when MBHP: Denies a request to authorize payment for a service or authorizes payment for less service than requested; Denies a request to authorize payment for a service because it is not a covered service; or Reduces, suspends, or terminates a previous authorization to pay for a service. It is also an Adverse Action when MBHP fails to follow required policies and procedures. These kinds of Adverse Actions happen when: You didn t receive covered services within the waiting times described in your Member Handbook or MBHP didn t decide a request for prior authorization for a service within the timeframes described in your Member Handbook. You can file an appeal of an Adverse Action with MBHP by telephone, in person, or by mail (see below for more information on these different ways to file your appeal). You must do this within 30 days of the date of any letter from MBHP telling you about an Adverse Action. If you did not receive such a letter from MBHP, you must file your appeal within 30 calendar days of learning on your own that an Adverse Action happened. You should be aware that if you submit your appeal after 30 days have passed, MBHP may dismiss your appeal by sending you a letter. This is a dismissal letter. If you believe that your appeal was, in fact, filed within 30 days, you can write to MBHP within 10 days of receiving the dismissal letter and ask MBHP to reconsider its dismissal. If MBHP agrees with you, it will process your appeal. If MBHP disagrees with you, it will send you a final letter dismissing your appeal. This is the final dismissal letter. If you still believe your appeal was filed properly, you can appeal to the Board of Hearings (see below for more information about the Board of Hearings appeal process). If the subject of your appeal is a decision by MBHP to reduce, suspend, or terminate a previous authorization to pay for a service that you are now receiving and you want to continue to receive that service during the appeal process, you must file your appeal request within 10 days of the date of any letter from MBHP telling you about its decision to reduce, suspend, or terminate your previous authorization. If you file your appeal within 10 days, you will continue to receive the 3/09 1

2 service that MBHP previously authorized while MBHP is deciding your appeal unless you tell MBHP that you want to stop receiving those services. You can appoint someone to file an appeal for you. It can be a family member, a friend, or your provider. If you want to do this, you should send MBHP a letter giving this person permission to act on your behalf as your authorized appeal representative. Mail this letter to: Massachusetts Behavioral Health Partnership Member Appeals Coordinator 150 Federal Street, Third Floor Boston, MA You have the right to give MBHP information explaining your appeal. You or your appeal representative can ask to appear in person to provide MBHP with information about your appeal or you can provide MBHP information about your appeal in writing. MBHP may need more information to carefully and completely consider your appeal. If it does, it will ask you or your providers for more information. Please respond to any requests from MBHP for additional information as soon as you can so that MBHP can make a prompt decision. Your appeal will be reviewed by two or more healthcare professionals who were not involved in the Adverse Action you are appealing. At least one of them will be an expert in the specific service addressed in your appeal. If you want to appeal by mail You or your appeal representative should write a letter explaining why you don t agree with MBHP s Adverse Action. Mail this letter to: Massachusetts Behavioral Health Partnership Member Appeals Coordinator 150 Federal Street, Third Floor Boston, MA If you want to appeal by telephone Call MBHP s Clinical Access Line at ; press 1 for the English menu or 2 for the Spanish menu, then press 4, then press 2. One of MBHP s Clinical Access Line clinicians will help you file your appeal. If you want to appeal in person Come to MBHP s offices on the third floor at 150 Federal Street in Boston during regular business hours (Monday through Friday, 8:30 a.m. through 5 p.m.). Ask to speak with the Appeals Coordinator, who will help you file your appeal. How long will MBHP take to decide your appeal? If your appeal is about outpatient services, MBHP will mail you its decision in writing within 5 business days after you file your appeal. If your appeal is about inpatient services, MBHP will mail you its decision in writing within 1 business day after you file your appeal. 3/09 2

3 You, your appeal representative, or MBHP may request to extend the timeframes for resolving an appeal for up to 5 calendar days. MBHP can only request an extension if the extension is in your best interests and there is a need for additional information. If MBHP requests an extension and you disagree with this request, you or your appeal representative may file a grievance with MBHP in writing, over the telephone, or in person. For more information about grievances, call ; press 1 for the English menu or 2 for the Spanish menu, then press 4, then press 1. If MBHP does not resolve your appeal within these timeframes (including extensions), you can immediately request to present your appeal to the MassHealth Board of Hearings (see below for more information about the Board of Hearings appeal process). Appeals in emergency situations You or your appeal representative may request an expedited (quick) appeal if you think your life or health would be seriously at risk if MBHP followed the timeframes described above for deciding your appeal. You can file an expedited (quick) appeal request by telephone, in person, or by mail (see above for more information on these different ways to file your appeal). Be sure to say that you want an expedited (quick) appeal and explain why. MBHP will decide if your request meets the requirements for an expedited appeal. If MBHP decides that it does not meet the requirements, MBHP will notify you in writing within 2 calendar days and will decide your appeal within the timeframes above for standard appeals. If your provider is acting as your appeal representative and asks that your appeal be expedited, or if your provider is not acting as your appeal representative but still supports your request that your appeal be expedited, MBHP will treat your appeal as an expedited appeal unless MBHP determines that the provider s request is unrelated to your health. You or your appeal representative can file a grievance with MBHP in writing, over the telephone, or in person if you do not agree with MBHP s decision not to expedite your appeal. For more information about grievances, call ; press 1 for the English menu or 2 for the Spanish menu, then press 4, then press 1. If MBHP decides that your appeal will be considered on an expedited basis, MBHP will decide your appeal on the same day and will call you that day with its decision on your appeal. MBHP will also notify you of its decision in writing within one business day. You, your appeal representative, or MBHP may request to extend the timeframes for resolving an expedited appeal for up to 14 calendar days. MBHP can only request an extension if the extension is in your best interests and there is a need for additional information. If MBHP requests an extension and you disagree with this request, you or your appeal representative may file a grievance with MBHP in writing, over the telephone, or in person. For more information about grievances, call ; press 1 for the English menu or 2 for the Spanish menu, then press 4, then press 1. If MBHP does not resolve your expedited appeal within these timeframes (including extensions), you can immediately request to present your expedited appeal to the MassHealth Board of Hearings (see below for more information about the Board of Hearings appeal process). 3/09 3

4 If MBHP denies your appeal or does not decide it within the required timeframes, you can appeal to the MassHealth Board of Hearings If you are not satisfied with MBHP s decision about your standard or expedited appeal or if MBHP did not decide your standard or expedited appeal during the required timeframes described above, you have the right to a hearing with the MassHealth Board of Hearings. When MBHP denies your appeal, it will provide you with instructions about how to request such a hearing. Also, MBHP will generally send you a letter if it does not decide your appeal within the required timeframes which will tell you about your right to appeal to the Board of Hearings and will instruct you how to request such a hearing. However, you do not need to wait for this letter to appeal to the Board of Hearings. MBHP will assist you in completing the application for a hearing. For help, call MBHP ; press 1 for the English menu or 2 for the Spanish menu, then press 4, then press 2. You cannot request a hearing at the Board of Hearings until you have completed MBHP s appeal process unless MBHP did not decide your appeal during the required timeframes described above. The Board of Hearings must receive your request for a hearing within 30 calendar days from the date of MBHP s decision to deny your appeal. However, if your appeal was an expedited appeal with MBHP and you are requesting an expedited hearing at the Board of Hearings, you must submit the request within 20 days. If the subject of your appeal is a decision by MBHP to reduce, suspend, or terminate a previous authorization to pay for a service and you want to continue to receive that service during the Board of Hearings appeal process, you must file your request with the Board of Hearings within 10 days from the date of MBHP s decision to deny your appeal. If you file your appeal within 10 days, you will continue to receive the service that MBHP previously authorized until the Board of Hearings reaches a decision unless you tell you tell MBHP that you want to stop receiving those services. You may be required to pay the cost of services you receive while the Board of Hearings is deciding your appeal if it agrees with MBHP s decision. If you are appealing to the Board of Hearings because MBHP did not decide your appeal during the required timeframes described above, you must file your request with the Board of Hearings within 30 days from the date that MBHP should have decided your appeal. If MBHP sent you a letter telling you that the timeframes passed, then you must file your appeal within 30 days of receiving that letter. To file your appeal with the Board of Hearings, you must complete a Request for Fair Hearing form and mail it, along with any required information, to the following address: Board of Hearings Executive Office of Health and Human Services 2 Boylston Street Boston, MA FAX: (617) /09 4

5 MBHP can provide you with a copy of the Request for Fair Hearing form and will assist you with requesting a Fair Hearing. For assistance, call ; press 1 for the English menu or 2 for the Spanish menu, then press 4, then press 2. Please note that you can call MBHP to have this handout read to you or if you want to have a Spanish version sent to you. All written materials sent to Members are also available in Spanish, and can also be read to you by a Community Relations Representative. For copies of materials in English, Spanish, or for oral interpretations into other languages or to have written materials read to you, please call Community Relations at (press 1 for the English menu or 2 for the Spanish menu, then press 4, then 1 to skip prompts), Monday through Thursday, 8 a.m.-5 p.m., and Friday, 9:30 a.m.-5 p.m. (English and other languages). To find a mental health provider, call the MBHP Clinical Access Line at (press 1 for the English menu or 2 for the Spanish menu, then press 4, then 2 to skip prompts), 24 hours a day, 365 days a year. 3/09 5