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Beneficiary Problem Resolution

County of Santa Clara Health System

Beneficiary Problem Resolution

 Policy & Procedure Manual (BHSD #12000)   Click the link to open in .pdf format​

 
Beneficiaries that receive BHSD services may file a grievance or appeal and have their concerns addressed through a clearly defined problem resolution process if they are not satisfied with their behavioral health services or steps taken by BHSD.  The Policy and Procedure Manual is used  for both  MH and SUTS as this is an integrated policy for Behavioral Health Department Beneficiary Problem Resolution Process. 
Following is a description of the organizational layout of the Manual to assist you in finding the information you need. The Manual consists of a Table of Contents, the Reference,  Policy, Definition, Procedure, Responsible Party /Action Required, Timeline Standards , and the Attachments. 
     Table of Contents

Reference

Policy              

Definitions:

Appeal.   A review by BHSD or Contract Agency of an adverse benefit determination.

Beneficiary.  A Medi-Cal recipient who is currently receiving services from BHSD or a BHSD contracted provider.

Grievance.  An expression of dissatisfaction about any matter other than adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect  the beneficiary’s rights regardless of whether remedial actions requested. Grievance includes a beneficiary’s right to dispute an extension of   time proposed by BHSD to make an authorization decision. (42 C.F.R. §   438.400)

Provider.    A person or entity who is licensed, certified, or otherwise recognized or authorized under state law governing the healing arts to  provide  specialty mental health services and who meets the standards for participation in the Medi-Cal program as described in California Code of  Regulations, title 9, Division 1, Chapters 10 or 11 and in Division 3, Subdivision 1 of Title 22, beginning with Section 50000. Provider includes but is not limited to licensed mental health professionals, clinics, hospital outpatient departments, certified day treatment facilities, certified residential treatment facilities, skilled nursing facilities, psychiatric health facilities, general acute care hospitals, and acute psychiatric hospitals. The MHP is a provider when direct services are provided to beneficiaries by employees of the Mental Health Plan.

Procedure  

Responsible Party/Action Required ​​​

Timeline Standards

Attachments (Templates): ​​

Last updated: 5/16/2019 3:41 PM