If you are unhappy with any of your services, please call CBH at 1-888-545-2600 and speak with a Member Services Representative.

Or you can write CBH at:
CBH
801 Market Street, 7th Floor
Philadelphia, PA 19107
ATTN: Quality Management

CBH has a special way to handle your concerns. The following information tells you what to do if you have a concern about your mental health or substance use services.

What Kind of Help May I Have with the Complaint and Grievance Processes?

If you need help filing your complaint or grievance, a staff member of CBH will help you. This person can also represent you during the complaint or grievance process. You do not have to pay for the help of a staff member. This staff member will not have been involved in any decision about your complaint or grievance.

You may also have a family member, friend, lawyer or other person help you file your complaint or grievance. This person can also help you if you decide you want to appear at the complaint or grievance review. For legal assistance you may contact your local legal aid office.

At any time during the complaint or grievance process, you may have someone you know represent you or act on your behalf. If you decide to have someone represent or act for you, please contact CBH Member Services for CBH’s Personal Representative Form.

You or the person you choose to represent you may ask CBH to see any information we have about your complaint or grievance.

Persons Whose Primary Language is Not English

If you ask for language interpreter services, services will be provided at no cost to you.

Persons with Disabilities

CBH will provide persons with disabilities with the following help in presenting complaints or grievances at no cost, if needed. This help includes:

  • TTY: 1-888-436-7482
  • Providing sign language interpreters;
  • Providing information submitted by CBH at the complaint or grievance review in an alternative format. The alternative format version will be given to you before the review; and
  • Providing someone to help copy and present information.

What is a Complaint?

A complaint is when you tell us you are unhappy with CBH or your provider or you do not agree with a decision made by CBH.

These are some examples of a complaint:

  • You are unhappy with the care you are getting.
  • You are unhappy that you may not get the service you want because it is not a covered service.
  • You are unhappy that you have not received services that you have been approved to get.*
  • You are unhappy that CBH will not pay a provider for a service you received.
  • You are unhappy that CBH did not decide a first level complaint or grievance within 30 days of when you filed it.

Who Can File a Complaint?

  • Members
  • Legal guardians of members (if member is 17 or younger)
  • A member’s chosen representative, with the member’s written consent
  • A health care provider, with the member’s written consent

What Should I Do if I Have a Complaint?

First Level Complaint

To file a complaint, you may:

  • Call CBH at 1-888-545-2600 and tell us your complaint, or
  • Write down your complaint and send it to us at:
    CBH
    801 Market Street, 7th Floor
    Philadelphia, PA 19107
    ATTN: Quality Management

When should I file a first level complaint?

You must file a complaint within 60 days from the date of the incident complained of or the date that you receive written notice of a decision, for the following areas:

  • CBH has decided you may not get a service you want because it is not a covered service.
  • CBH failed to meet the required time frames for providing a service.
  • CBH will not pay a provider for a service you received.
  • CBH did not decide a first level complaint or grievance you filed earlier within 30 days of when you filed it.

You may file all other complaints at any time.

What Happens After I File a First Level Complaint?

CBH will send you a letter to let you know we received your complaint. The letter will tell you about the first level complaint process.

You may participate in the first level process by presenting testimony and evidence and make legal and factual arguments, in person as well as in writing. If you do not attend, it will not effect CBH’s decision. Quality Management staff may contact you throughout the complaint investigation process. You may ask CBH to see any information we have about your complaint.

If you filed a complaint, you may be included in the first level complaint review. You must call CBH within 7 business days of the date on the letter to tell us that you want to be included:

A complaint review committee comprised of individuals not involved in the process will review your complaint. If the complaint is clinically related, a CBH physician or psychologist will be part of the committee. The complaint review committee will review all of the findings and make a determination of Supported, Not Supported, or Partially Supported.

CBH must send written notice of the Complaint decision to you, your representative (if designated), service provider and prescribing provider (if applicable) within 30 calendar days from the date CBH received the Complaint, unless the timeframe for deciding the Complaint has been extended by up to 14 calendar days by you.

The written notice will tell you the reason(s) for the decision. It will also tell you how to file a second level complaint if you don’t like the decision.

What to Do to Continue Getting Services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a complaint that is hand delivered or postmarked within 1 day from the mail date on the written notice of decision if acute inpatient psychiatric treatment, medically monitored detoxification, medically managed detoxification, or medically monitored short-term rehabilitation, or 10 days from the mail date on the written notice of decision if any other services, telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made.

What if I Do Not like CBH’s Decision About My First Level Complaint?

Second Level Complaint
If you are not happy with CBH’s first level complaint decision, you may file a second level complaint with CBH.

When should I file a second level complaint?
You must file your second level complaint within 45 days from the date you receive written notice of CBH’s first level complaint decision.

What happens after I file a second level complaint?
CBH will send you a letter to let you know we received your complaint. The letter will tell you about the second level complaint process.

You may ask CBH to see any information we have about your complaint. You may also send information that may help with your complaint to CBH.

You may come to a meeting of the second level complaint committee or be included by phone. CBH will ask you how you want to participate. You don’t have to attend if you do not want to. If you do not attend, it will not affect our decision. You will be asked if you want the provider to participate. If you do not consent the provider will not be part of the second level process.

The second level complaint review committee will have three or more people on it. At least one individual will be a consumer representative. The members of the committee will not have been involved in the issue you filed your complaint about or any previous level. CBH must send a written notice of the second level complaint decision to the member, member’s representative (if designated), service provider, and prescribing provider (if applicable) within 45 days from the date CBH receives the second level complaint. This letter will tell you the reason for the decision. It will also tell you how to ask for an external complaint review if you don’t like the decision.

What to Do to Continue Getting Services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a complaint that is hand delivered or postmarked within 1 day from the mail date on the written notice of decision if acute inpatient psychiatric treatment, medically monitored detoxification, medically managed detoxification, or medically monitored short-term rehabilitation, or 10 days from the mail date on the written notice of decision if any other services, telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made.

What If I Still Don’t Like the Decision?

External Complaint Review
If you are not happy with CBH’s second level complaint decision, you may ask for a review of your complaint by the Department of Health or the Insurance Department. The Department of Health handles complaints that involve the way a provider gives care or services. The Insurance Department reviews complaints that involve CBH policies and procedures.

You must ask for an external review within 15 calendar days from the date you receive the written notice of CBH’s second level complaint decision.

If you ask, the Department of Health will help you put your complaint in writing. You must send your request for external review in writing to either:

Pennsylvania Department of Health
Bureau of Managed Care
Health & Welfare Building, Room 912
625 Forster Street
Harrisburg, PA 17120-0701
Telephone: 1-888-466-2787
Fax: 1-717-705-0947
AT&T Relay: 1-800-654-5984 (for persons with hearing impairments)

or

Pennsylvania Insurance Department
Bureau of Customer Service
1321 Strawberry Square
Harrisburg, PA 17120
Telephone: 1-877-881-6388

If you send your request for external review to the wrong department, it will be sent to the correct department.

The Department of Health or the Insurance Department will get your file from CBH. You may also send them any other information that may help with the external review of your complaint.

The Department of Health or the Insurance Department will send a decision to you after the decision is made. This letter will tell you the reason(s) for the decision and what you may do if you don’t like the decision.

What to Do to Continue Getting Services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a complaint that is hand delivered or postmarked within 1 day from the mail date on the written notice of decision if acute inpatient services, or 10 days from the mail date on the written notice of decision if any other services telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made.

What is a Grievance?

Sometimes CBH will decide that a service you or your provider ask for is not medically necessary for you. If you do not agree with this decision, you can file a grievance.

You may file a grievance if CBH does any one of these things:

  • Denies a service
  • Approves a service in a lesser amount than was asked for
  • Approves a service for a shorter time period than was asked for
  • Approves a different service from the one that was asked for

Who can file a Grievance?

  • Members
  • Legal guardians of members (if the member is 17 or younger)
  • A member’s chosen representative, with the member’s written consent
  • A health care provider, with the member’s written consent

What Should I do if I have a Grievance?

First Level Grievance
If CBH does not completely approve a service for you, we will tell you in a letter. The letter will tell you how to file a grievance. You have 60 days from the date you receive this letter to file a grievance.

To file a grievance, you may:

  • Call CBH at 1-888-545-2600 and tell us your grievance, or
  • Write down your grievance and send it to us at:
    CBH
    801 Market Street, 7th Floor
    Philadelphia, PA 19107
    ATTN: Quality Management

NOTE: If your provider files a grievance for you, you cannot file a separate grievance on your own.

What Happens After I File a First Level Grievance?

CBH will send you a letter to let you know we received your grievance. The letter will tell you about the first level grievance process.

You may ask CBH to see any information we have about your grievance. You may also send information that may help with your grievance to CBH.

If you want to be included in the first level grievance review, you must call us within 10 days of the date on the letter we sent you to let you know we received your grievance. You may come to our offices or be included by phone. You don’t have to attend if you do not want to. If you do not attend, it will not effect our decision.

A committee of one or more CBH staff, including a doctor or licensed psychologist, who has not been involved in the process, will make a decision about your first level grievance. Your grievance will be decided no more than 30 days after we received it.

CBH must send written notice of the grievance decision to the member, member’s representative (designated), service provider, and prescribing provider, if applicable within 30 days from the date CBH received the grievance, unless the timeframe for deciding the grievance has been extended by up to 14 calendar days at the request of the member.

What to Do to Continue Getting Services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a grievance that is hand delivered or postmarked within 1 day from the mail date on the written notice of decision if acute inpatient psychiatric treatment, medically monitored detoxification, medically managed detoxification, or medically monitored short-term rehabilitation, or 10 days from the mail date on the written notice of decision if any other services telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made.

If you need help or have questions about complaints and grievances, you may call CBH’s toll free telephone number at 1-888-545-2600, your local legal aid office, or call the Pennsylvania Health Law Project at 1-800-274-3258.

What if I Still Don’t Like the Decision?

External Grievance Review
If you are not happy with CBH’s decision, you may ask for an external grievance review.

You must call or send a letter to CBH asking for an external grievance review within 15 days of the date you received the grievance decision letter. We will then send your request to the Department of Health.

The Department of Health will notify you of the external grievance reviewer’s name, address, and phone number. You will also be given information about the external review process.

CBH will send your grievance file to you and the reviewer. You may provide additional information that may help with the external review of your grievance, to the reviewer, within 15 days of filing the request for an external grievance review.

You will receive a decision letter from the external review entity. This letter will tell you the reason(s) for the decision and what you may do if you don’t like the decision.

What to Do to Continue Getting Services:

If you have been receiving services that are being reduced, changed, or stopped because they are not covered services for you and you file a grievance that is hand delivered or postmarked within 1 day from the mail date on the written notice of decision if acute inpatient psychiatric treatment, medically monitored detoxification, medically managed detoxification, or medically monitored short-term rehabilitation, or 10 days from the mail date on the written notice of decision if any other services telling you that the services you have been receiving are not covered services for you, the services will continue until a decision is made.

Expedited Complaints and Grievances

What can I do if my health is at immediate risk?
If your doctor believes that the usual timeframes for deciding your complaint or grievance will harm your health, you or your doctor can call CBH at 1-888-545-2600 and ask that your complaint or grievance be decided faster.

You will need to have a letter from your doctor faxed to 1-215-413-7132 explaining how the usual timeframe of 30 days for deciding your complaint or grievance will harm your health. This letter must be received by CBH within 72 hours from your request. If not received, CBH will follow normal 30-day process. Once CBH receives your doctor’s letter, CBH will make a decision within 48 hours of receiving the provider’s certification or 72 hours of receiving your request for an expedited review, whichever is shorter.

If your doctor does not fax CBH this letter, your complaint or grievance will be decided within the usual timeframes.

Expedited Complaint
A committee of 3 or more people, including a physician and a consumer representative, will review your complaint. No one on the committee will have been involved in the issue you filed your complaint about.

You will receive a letter telling you the reason for the decision. The letter will explain how to ask for an expedited external complaint review if you don’t like the decision.

How Do I Ask for a Fair Hearing?

In order to file a fair hearing, you must go through the grievance process first and receive a decision. Fair hearings must be requested within 120 days of the date on the grievance decision notice. To ask for a fair hearing, you must ask for a fair hearing in writing and send it to:

Department of Human Services
Office of Mental Health and Substance Use Services
Division of Quality Management –
Commonwealth Towers, 12th Floor
P.O. Box 2675
Harrisburg, PA 17105-2675

Your request for a fair hearing should include the following information:

  • the member’s name and date of birth;
  • a telephone number where you may be reached during the day;
  • if you want to have the fair hearing in person or by telephone; and
  • any letter you may have received about the issue you are requesting your fair hearing for.

What Happens After I Ask for a Fair Hearing?

You will get a letter from the Pennsylvania Department of Human Services Bureau of Hearings and Appeals telling you where the hearing will be held and the date and time for the hearing. You will receive this letter at least 10 days before the date of the hearing.

You may come to where the fair hearing will be held or be included by phone. A family member, friend, lawyer or other person may help you during the fair hearing.

CBH will also go to your fair hearing to explain why we made the decision or explain what happened.

CBH will give you (at no cost to you) any records, reports and other information we have that is relevant to what you requested your hearing about.

When Will the Fair Hearing Be Decided?

The Bureau of Hearings and Appeals will issue a decision within 90 calendar days of when you filed the request with CBH.

A letter will be sent to you after the decision is made. This letter will tell you the reasons for the decision. It will tell you what to do if you don’t like the decision.

What to Do to Continue Getting Services:

If you have been receiving services that are being reduced, changed or stopped, and you must file a grievance that is hand delivered or postmarked within 1 calendar day for acute inpatient psychiatric treatment, medically monitored detoxification, medically managed detoxification, or medically monitored short-term rehabilitation or within 10 calendar days for all other services of the date on the letter (notice) telling you that the services you have been receiving are being reduced, changed, or stopped, the services will continue until a decision is made.

What Can I Do if My Health is at Immediate Risk?

Expedited Fair Hearing
If your doctor believes that using the usual timeframes to decide your fair hearing will harm your health, you or your doctor or licensed psychologist can call the Pennsylvania Department of Human Services at 1-877-356-5355 and ask that your fair hearing be decided faster. This is called an expedited fair hearing.

You will need to have a letter from your doctor or licensed psychologist faxed to 1-717-772-7827 explaining why using the usual timeframes to decide your fair hearing will harm your health. If your doctor does not send a written statement, your doctor may testify at the fair hearing to explain why using the usual timeframes to decide your fair hearing will harm your health.

The Bureau of Hearings and Appeals will contact you to schedule the expedited fair hearing. The Bureau of Hearings and Appeals will issue a decision within 3 business days from receipt of your request.

If your doctor does not send a written statement and does not testify at the fair hearing, the fair hearing decision will not be expedited. Another hearing will be scheduled and decided within 90 days.

If you need help or have questions about fair hearings, you may call CBH’s toll free telephone number at 1-888-545-2600, the Pennsylvania Legal Aid Network at 1-800-322-7572 (www.palegalaid.org), or the Pennsylvania Health Law Project at 1-800-274-3258.