Outpatient Mental Health Services
45. Weight Control or Exercise Programs Does not include medically necessary
surgery as authorized by the plan or programs offered by CCHP health education.
In addition, the following services are not covered benefits by CCHP. They may be covered under some other specially funded program or under Medi-Cal Fee-For- Service.
x Prayer Healing
x Dental and Orthodontics (Denti-Cal) Beneficiary Telephone Service Center 1-800-322-6384
x California Children’s Services x Acupuncture
x Chiropractic
x Methadone/Outpatient Heroin Drugs x Alcohol and Drug Treatment Services
available under Short-Doyle Medi-Cal (SDMC) Program
x Local Education Agency (LEA) Service Antipsychotic drugs specifically excluded under CCHP’s contract with DHCS, HIV/Antiviral, and Anti-Parkinson’s Drugs If you need Long-Term Care, or an organ transplant and are accepted as a transplant candidate (except renal or corneal) or enroll in a Medi-Cal home and community based
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Medi-Cal Evidence of Coverage & Disclosure Form waiver program you may be disenrolled by
the state Health Care Options contractor and go back to Fee-For-Service Medi-Cal. Call a Member Services Representative to assist you. However, you may stay in CCHP if you enroll in the Multi-Purpose Senior Services Program (MSSP). ). If you are placed in a Medi-Cal Home and Community Based Services (HCBS) waiver program, you will continue to be enrolled in CCHP but you will receive your HCBS services from the waiver program. Long-term care includes care in a nursing facility such as a Skilled Nursing Facility, sub-acute nursing facility, pediatric sub-acute facility or intermediate care facility.
SECTION 8. COMPLAINTS AND
GRIEVANCES
Resolution of Complaints and Grievances
If you have a concern or complaint about any CCHP services, you can file a grievance and CCHP will make a decision about your grievance within thirty (30) days. You can informally try and talk about the problem where it occurred, but you are not required to do so. If you have a concern or complaint about your doctor or any provider, you can also try to talk about the problem with your doctor or provider, but you are not required to do so. You may use CCHP’s formal grievance process at any time. Call Member Services to help you at 1-877-661-6230 (press 2), for hearing impaired call California Relay at 1-800-735-2929. You can write a complaint to CCHP, phone us or come and talk about the problem. Our CCHP providers also have grievance forms in their offices. Our address is:
Contra Costa Health Plan 595 Center Avenue, Suite 100
Martinez, CA 94553 1-877-661-6230 (press 2)
for Hearing Impaired call California Relay at 1-800-735-2929
If you file a complaint, your Member Services Representative will try to solve the problem. They will always try to answer your questions and solve your complaints at the time when first contact is made.
If this does not work, you may file a “grievance” which is a written or verbal expression of dissatisfaction. All complaints and grievances will be resolved within thirty (30) days. You may write us at the above address or call Member Services at 1-877- 661-6230 (press 2), California Relay 1-800- 735-2929. You may also find a grievance
form on our website at:
https://mmm.co.contra-costa.ca.us/cchp/. The following steps will help solve your complaint.
x All grievances will be given to a Member Services Representative;
x All grievances are considered secret (confidential) and information is used only to investigate and resolve your grievance. We will keep information in a safe and protected place and we will follow our rules of keeping medical information secret (confidential);
x If you file a grievance, CCHP will tell you in writing that we got it within five (5) days;
x CCHP will give you a specific Member Service Representative’s name and phone number to contact;
x Within thirty (30) days after we get your grievance, CCHP will review and make a decision. CCHP provides only one level of grievance resolution or appeals; x You have one hundred eighty (180) days
after a concern or complaint to file a grievance;
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Medi-Cal Evidence of Coverage & Disclosure Form
Rev. 08.21.14 EOC-44 Medi-Cal 2014-2015_EOC
grievance is being reviewed and resolved.
Expedited Review of Grievances
The Expedited Review Process applies to requests for services or supplies that:
x You believe are medically urgent but you have not gotten an okay or a referral for services; or
x You are getting and you think are medically urgent, and CCHP should keep providing.
You may ask CCHP to use this process when you file a grievance or a request for consideration. We will use the Expedited Review Process if waiting thirty (30) days for a decision might seriously harm your health. For reviews that require expedited handling, we will give an answer no later than three (3) days after we get your request. If we deny your request for an expedited review, we will tell you in writing within three (3) days and use the regular thirty (30) days’ grievance process to review your request.
Whenever there is a case needing an expedited review, you also have the right to tell the Department of Managed Healthcare of the grievance.
Appeals Process for Claims and Services
Denials for reimbursement or benefits may be the subject of a grievance. If you feel: x That you have not been given a needed
benefit of CCHP, or
x You need pay back for something you paid for.
You may send Member Services a written or verbal request for reconsideration within ninety (90) days of the date of CCHP’s denial. CCHP will answer your written or verbal request for reconsideration within thirty (30) days of receipt. Please read below
for more information on Medi-Cal Fair Hearings.
Medi-Cal Fair Hearing Right
You have the right to use the Medi-Cal Fair Hearing process. You don't need to file a complaint or grievance with CCHP or wait for a complaint or grievance to be decided by CCHP.
You have only ninety (90) days after the order or action you are complaining of to file your Fair Hearing. You may go yourself or have someone else talk for you. This can be a lawyer, relative, friend or anyone you decide to bring.
To file a Fair Hearing, call 1-800-952-5253 (TDD call 1-800-952-8349) or write to: California Department of
Social Services
P.O. Box 944243, MS 9-17-37 Sacramento, CA 94244-2430
Faster (Expedited) Medi-Cal Fair Hearing Process
You or your doctor can ask the state to decide your Medi-Cal Fair Hearing request faster if it involves imminent and serious threat to your health (such as severe pain or potential loss of life, limb, or major body function).
To ask for a faster decision, call 1-800-952- 5253 (TDD call 1-800-952-8349) or write to:
California Department of Social Services Expedited Hearings Unit
State Hearings Division
744 P Street, Mail Station 9-17-37 Sacramento, CA 95814
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Medi-Cal Evidence of Coverage & Disclosure Form
Filing a Complaint with the Department of Managed Health Care (DMHC)
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1- 877-661-6230 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s
Internet Web site
http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
Right to Conference
If you are terminally ill and CCHP says you
cannot have an experimental or
investigational service, you have one hundred eighty (180) days to write to Member Services to ask for a conference. If you cannot meet this deadline, please call Member Services at 1-877-661-6230 (press
2), for hearing impaired call California Relay at 1-800-735-2929 for how to proceed.
x Within five (5) business days from the denial, CCHP will give you information about grievance procedures and how to ask for a conference.
x You will be told exactly why your coverage was denied. x You will be told about other
types of treatments, services, or supplies covered by CCHP, if any.
x Within thirty (30) days of receiving a request for a conference, CCHP will set up a conference with you and the people you pick to talk about why CCHP denied coverage and if there are other possible choices. Someone from CCHP with power to decide on the complaint will run the conference.
x If your doctor and the CCHP’s Medical Director think that a delay in treatment will make it substantially less effective, CCHP will set up a conference within five (5) business days after your request. In addition to requesting a conference, you
can also immediately request an
Independent Medical Review (IMR) with the Department of Managed Health Care. See the section below for more information on IMR. You may also call the department at toll-free telephone number (1-888-HMO- 2219) and TDD line (1-877-688-9891) for the hearing and speech impaired.
Independent Medical Review (IMR) - Independent Medical Review of
Experimental or Investigational Services
If CCHP has decided not to give you a service, drug, device, procedure, or other therapy (referred to as “Requested Service”) because it is an experimental or investigational service, you may ask for an
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Medi-Cal Evidence of Coverage & Disclosure Form
Rev. 08.21.14 EOC-46 Medi-Cal 2014-2015_EOC
Department of Managed Health Care’s (DMHC) Independent Medical Review (IMR) process. You may qualify for this review if:
x Your doctor certifies that you have a life threatening or seriously debilitating condition; and
x Your doctor certifies that standard treatments have not been effective in improving the condition; and
x Your doctor has recommended the requested service that may be more helpful than any available standard treatment; and
x CCHP has denied you coverage of this requested service; and
x This requested service would be of benefit to you if it were not considered an experimental or investigational service.
Note:
x If you are eligible, CCHP will notify you in writing of the opportunity to request an IMR within five business days of the decision to deny coverage;
x The Department of Managed Health Care does not require that you participate in CCHP’s grievance system prior to seeking an IMR of a denial for an experimental or investigational therapy;
x If your doctor determines that the proposed therapy would be significantly less effective if not promptly initiated, the analyses and recommendation of the experts on the IMR panel shall be rendered within seven (7) days of the request for expedited review.
Independent Medical Review (IMR) of Denials based on Medical Necessity
You may also ask for an Independent Medical Review of disputed health care service from the Department of Managed Health Care if you think that health care
service has been wrongly denied, modified or delayed by CCHP or by one of our contracted providers.
A “disputed health care service” is any health care service eligible for coverage and payment under your subscriber contract which has been denied, modified or delayed wholly or partly by CCHP or one of our contracting providers because the service is not medically necessary.
The Independent Medical Review process is in addition to any other procedures or remedies that may be available to you. There are no application or processing fees for an Independent Medical Review. You have the right to give information in support of the request for an Independent Medical Review. An Independent Medical Review application form must come with any grievance decision letter you get from CCHP that denies, modifies or delays health care services because they are not medically necessary. If you decide not to use the Independent Medical Review process, this may cause you to give up any statutory right to pursue legal action against CCHP regarding the disputed health care services.
How Eligibility for Independent Medical Review Will Be Decided
The DMHC shall have the final authority to determine whether a case qualifies for IMR. Your application for Independent Medical Review will be reviewed by the DMHC to make sure that:
1. (a) Your provider has recommended a health care service as medically necessary; or
(b) You have gotten Urgent Care Services or Emergency Services that a provider determined were medically necessary; or
(c) You have been seen by an in-plan (contracted) provider for the diagnosis or
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Medi-Cal Evidence of Coverage & Disclosure Form treatment of the medical condition for
which you seek independent medical review;
2. The disputed health care service has been denied, modified, or delayed by CCHP or one of the contracted providers, based wholly or partly because the health care service is not medically necessary; and
3. You have filed a grievance or a request for reconsideration with CCHP or its contracting provider and the disputed decision is upheld or remains unresolved after thirty (30) days. If your grievance or request for reconsideration requires expedited review, you may bring it immediately to the attention of the Department of Managed Health Care. In unusual cases, the Department of Managed Health Care may not require that you follow CCHP’s grievance process.
If your case is found to be eligible for Independent Medical Review, the dispute will be given to a medical specialist who will make an independent finding of whether or not the care is medically necessary. You will get a copy of the findings made in your case. If the Independent Medical Review finds the service is medically necessary for you, CCHP will give the health care services.
x For non-urgent cases, the Independent Medical Review organization designated by the Department of Managed Health Care must give its finding within thirty
(30) days after receiving your
Independent Medical Review application and supporting documents.
x For urgent cases involving immediate and serious threat to your health, including but not limited to: potential loss of life, limb or major bodily function, severe pain, or the immediate and serious worsening of your health,
the Independent Medical Review organization must give its finding within three (3) business days.
For more information about the Independent Medical Review Process, or to ask for an application form, please call the Department of Managed Health Care. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The
department’s Internet Web site
http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
Kaiser Permanente Grievance Processes
Kaiser Permanente Member Services Representatives will handle your grievances if you are assigned to the Kaiser Permanente Network. Please call 1-800-464-4000 to file a grievance at Kaiser. If you’re not satisfied with the way your grievance is answered, you may call the Contra Costa Member Services Unit at 1-877-661-6230 (press 2), or for hearing impaired call California Relay 1-800-735-2929 for more help.
California DHCS Ombudsman Program
The California Department of Health Care Services has a Medi-Cal Ombudsman Program that can help you with complaints about a Medi-Cal Managed Care health plan or enrollment into a Medi-Cal health plan. If you need assistance, call 1-888-452-8609. You also have the right to change your health plan at any time.