Complaints, Grievances, and Fair Hearings

Some Complaints have a time limit on filing. You must file a Complaint within 60 days of getting a notice telling you that

• CBH has decided that you cannot get a service you want because it is not a covered service.
• CBH did not tell you its decision about a Complaint or Grievance you told CBH about within 30 or fewer days from when CBH received your Complaint or Grievance.
• A denial of payment by CBH after a service(s) has been delivered because the service was provided without authorization by a provider not enrolled in the Pennsylvania Medical Assistance Program.
• A denial of payment by CBH after a service(s) has been delivered because the service is not a covered service for the member.
• A denial of a member’s request to dispute financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.
• The failure of CBH to meet the required time frames for providing a service.

You must file a Complaint within 60 days of the date you should have gotten a service if you did not get a service. The time by which you should have received a service is listed below:

• If you need services because of an emergency, services must be provided within one hour.
• If you need services because of an urgent situation, services must be provided within 24 hours.
• If you need a routine appointment or specialty referral, your appointment must be within seven days.

You may file all other Complaints at any time.

After you file your Complaint, you will get a letter from CBH telling you that CBH has received your Complaint, and it will explain the First Level Complaint review process.

You may ask CBH to see any information CBH has about the issue you filed your Complaint about at no cost to you. You may also send information that you have about your Complaint to CBH.

You may attend the Complaint review if you want to attend. You may appear at the Complaint review in person, by phone, or by videoconference. If you decide that you do not want to attend the Complaint review, it will not affect the decision.

A committee of one or more CBH staff who were not involved in, and do not work for someone who was involved in, the issue you filed your Complaint about will meet to make a decision about your Complaint. If the Complaint is about a clinical issue, a licensed doctor will be on the committee. CBH will mail you a notice within 30 days from the date you filed your First Level Complaint to tell you the decision on your First Level Complaint. The notice will also tell you what you can do if you do not like the decision.

If the Complaint is to dispute a decision to discontinue, reduce, or change a service that the member has been receiving because the service is not a covered service, the member must continue to receive the disputed service at the previously authorized level, pending resolution of the Complaint. If the Complaint is about acute inpatient service, it must be filed orally, hand-delivered, faxed, or post-marked within one day from the mail date on the written notice of decision; Complaints about all other services must be filed within 15 days from the mail date on the written notice of decision.

You may ask for an external Complaint review, a Fair Hearing, or an external Complaint review and a Fair Hearing if the Complaint is about one of the following:

• CBH’s decision that you cannot get a service you want because it is not a covered service.
• CBH’s failure to decide a Complaint or Grievance you told CBH about within 30 or fewer days from when CBH received your Complaint or Grievance.
• A denial of payment by CBH after a service(s) has been delivered because the service was provided without authorization by a provider not enrolled in the Pennsylvania Medical Assistance Program.
• A denial of payment by CBH after a service(s) has been delivered because the service is not a covered service for the member.
• A denial of a member’s request to dispute financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.
• The failure of CBH to meet the required time frames for providing a service.

You must ask for an external Complaint review within 15 days of the date you got the First Level Complaint decision notice.

You must ask for a Fair Hearing within 120 days from the date on the notice telling you the Complaint decision.

For all other Complaints, you may file a Second Level Complaint within 45 days of the date you got the Complaint decision notice.

If you have been getting the services that are being reduced, changed, or denied, and your request for an external Complaint review is postmarked or hand-delivered within one day of the date on the notice telling you CBH’s First Level Complaint decision that you cannot get acute inpatient services you have been receiving because they are not covered services for you, or within 15 days of the date on the notice telling you CBH’s First Level Complaint decision that you cannot get any other services you have been receiving because they are not covered services for you, the services will continue until a decision is made.

To file a Second Level Complaint:

• Call CBH at 888-545-2600 (TTY: 888-436-7482) and tell CBH your Second Level Complaint, or
• Write your Second Level Complaint and send it to CBH by mail or fax:
  Community Behavioral Health
  801 Market Street, 7th Floor
  Philadelphia, PA 19107
  ATTN: Quality Management
  Fax: 215-413-7132

After you file your Second Level Complaint, you will get a letter from CBH telling you that CBH has received your Complaint, and it will explain the Second Level Complaint review process.

You may ask CBH to see any information CBH has about the issue you filed your Complaint about at no cost to you. You may also send information that you have about your Complaint to CBH.

You may attend the Complaint review if you want to attend. CBH will tell you the location, date, and time of the Complaint review at least 10 days before the Complaint review. You may appear at the Complaint review in person, by phone, or by videoconference. If you decide that you do not want to attend the Complaint review, it will not affect the decision.

A committee of three or more people, including at least one person who does not work for CBH, will meet to decide your Second Level Complaint. Members of the committee will not have been involved in, and will not have worked for someone who was involved in, the issue you filed your Complaint about. If the Complaint is about a clinical issue, a licensed doctor will be on the committee. CBH will mail you a notice within 45 days from the date you filed your Second Level Complaint to tell you the decision on your Second Level Complaint. The letter will also tell you what you can do if you do not like the decision.

You may ask for an external review with the Pennsylvania Insurance Department.

You must ask for an external review within 15 days of the date you got the Second Level Complaint decision notice.

You must send your request for an external review of your Complaint in writing to:

Pennsylvania Insurance Department
Bureau of Consumer Services
1209 Strawberry Square
Harrisburg, PA 17120
Fax: 717-787-8585

You can also go to the “File a Complaint” page on the Pennsylvania Insurance Department website.

Your request for an external review by the Pennsylvania Insurance Department must include the following information:

• Member’s name, address, and daytime telephone number
• Member’s CBH identification number
• CBH’s name
• A brief description of the issue
• A copy of the notice

If you need help asking for an external review, you can call CBH at 1-888-545-2600 and CBH will assign someone who has not been involved in the Complaint issue and does not work for anyone who was involved in the Complaint issue to help you.

You can also call the Pennsylvania Insurance Department Bureau of Consumer Services at 1-877-881-6388.

The Pennsylvania Insurance Department Bureau of Consumer Services will get your file from CBH. You may also send them any other information that may help with the external review of your Complaint.

You may be represented by an attorney or another person, such as your representative, during the external review.

A decision letter will be sent to you after the decision is made. This letter will tell you the reason(s) for the decision and what you can do if you do not like the decision.

You must file a Grievance within 60 days from the date you get the notice telling you about the denial, decrease, or approval of a different service for you.

After you file your Grievance, you will get a letter from CBH telling you that CBH has received your Grievance, and the letter will explain the Grievance review process.

You may ask CBH to see any information that CBH used to make the decision you filed your Grievance about at no cost to you. You may also send information that you have about your Grievance to CBH.

You may attend the Grievance review if you want to attend. CBH will tell you the location, date, and time of the Grievance review at least 10 days before the day of the Grievance review. You may appear at the Grievance review in person, by phone, or by videoconference. If you decide that you do not want to attend the Grievance review, it will not affect the decision.

A committee of three or more people, including a licensed doctor, will meet to decide your Grievance. Members of the committee will not have been involved in, and will not have worked for someone who was involved in, the issue you filed your Grievance about. CBH will mail you a notice within 30 days from the date you filed your Grievance to tell you the decision on your Grievance. The notice will also tell you what you can do if you do not like the decision.

If you have been getting services that are being reduced, changed, or denied, and you file a Grievance verbally, or fax, postmark, or hand-deliver one within one day of the date on the notice telling you that acute inpatient services you have been receiving are being reduced, changed or denied, or within 15 days of the date on the notice telling you that any other services you have been receiving are being reduced, changed, or denied, the services will continue until a decision is made.

You may ask for an external Grievance review or a Fair Hearing, or you may ask for both. A Fair Hearing is your appeal presented at the Department of Human Services (DHS), Bureau of Hearings and Appeals to make a decision regarding your grievance. An external Grievance review is a review by a doctor who does not work for CBH.

You must ask for an external Grievance review within 15 days of the date you got the Grievance decision notice.

You must ask, in writing, for a Fair Hearing from DHS within 120 days from the date on the notice telling you the Grievance decision.

To ask for an external Grievance review:

• Call CBH at 888-545-2600 (TTY: 888-436-7482) and tell CBH your Grievance, or
• Write down your Grievance and send it to CBH by mail or fax:
  Community Behavioral Health
  801 Market Street, 7th Floor
  Philadelphia, PA 19107
  ATTN: Quality Management
  Fax: 215-413-7132

CBH will send your request for external Grievance review to the Pennsylvania Insurance Department, which will send you more information about the external review process.

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

CBH will send your Grievance file to the reviewer. You may provide additional information that may help with the external review of your Grievance to the reviewer within 20 days of the date the IRO assignment notice was mailed.

You will receive a decision letter within 60 days of the date you asked for an external Grievance review. This letter will tell you the reason(s) for the decision and what you can do if you do not like the decision.

If you have been getting the services that are being reduced, changed, or denied and you ask for an external Grievance review or a Fair Hearing, you must ask for an external review verbally or in a letter that is postmarked or hand-delivered within one day of the date on the notice telling you CBH’s Grievance decision that acute inpatient services you have been receiving are being reduced, changed, or denied or within 15 days of the date on the notice telling you CBH’s Grievance decision that any other services you have been receiving are being reduced, changed, or denied, and the services will continue until a decision is made. If you ask for both an external review and a Fair Hearing, you must ask for both within one business day if the services are acute inpatient; for all other levels of care, you must ask for both 15 days from the date on this notice. If you wait to ask for a Fair Hearing until after you receive a decision on your external Grievance, services will not continue.

A committee of three or more people, including a licensed doctor, will meet to decide your Grievance. The CBH staff on the committee will not have been involved in, and will not have worked for someone who was involved in, the issue you filed your Grievance about.

You may attend the expedited Grievance review if you want to attend. You can attend the Grievance review in person but may have to appear by phone or by videoconference because CBH has a short amount of time to decide on the expedited Grievance. If you decide that you do not want to attend the Grievance review, it will not affect the decision.

CBH will tell you the decision about your Grievance within 48 hours of when CBH receives your doctor’s letter explaining why the usual time frame for deciding your Grievance will harm your health or within 72 hours from when CBH gets your request for an early decision, whichever is sooner unless you ask CBH to take more time to decide your Grievance. You can ask CBH to take up to 14 more days to decide your Grievance. You will also get a notice telling you the reason(s) for the decision and what to do if you do not like the decision.

If you do not like the expedited Grievance decision, you may ask for an expedited external Grievance review or an expedited Fair Hearing by DHS or both an expedited external Grievance review and an expedited Fair Hearing.

You must ask for an expedited external Grievance review by the Pennsylvania Insurance Department within two business days from the date you get the expedited Grievance decision notice. To ask for expedited external review of a Grievance:

• Call CBH at 888-545-2600 (TTY: 888-436-7482) and tell CBH your Complaint,
• Send an email to CBH at Quality.Review@phila.gov, or
• Write down your Complaint and send it to CBH by mail or fax:
  Community Behavioral Health
  801 Market Street, 7th Floor
  Philadelphia, PA 19107
  ATTN: Quality Management
  Fax: 215-413-7132

CBH will send your request to the Pennsylvania Insurance Department. The Insurance Department will send you more information about the expedited external review process.

You must ask for a Fair Hearing within 120 days from the date on the notice telling you the expedited Grievance decision.

Your request for a Fair Hearing must be in writing.

Your Fair Hearing request needs to include the following information:

• Your (the member’s) name and date of birth;
• a telephone number where you can be reached during the day;
• whether you want to have the Fair Hearing in person or by telephone;
• the reason(s) you are asking for a Fair Hearing;
• a copy of any letter you received about the issue you are asking for a Fair Hearing about; and
• a copy of the original denial notice, if available.

You may mail or fax your request for a Fair Hearing to:

Department of Human Services
Office of Mental Health Substance Abuse Services
Division of Quality Management
Commonwealth Towers, 12th Floor
P.O. Box 2675
Harrisburg, PA 17105-2675
Fax: 717-772-7827

You will get a letter from the DHS 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. You MUST participate in the Fair Hearing.

CBH will also go to your Fair Hearing to explain why CBH made the decision or explain what happened.

You may ask CBH to give you any records, reports, and other information about the issue you requested your Fair Hearing about at no cost to you.

The Fair Hearing will be decided within 90 days from when you filed your Complaint or Grievance with CBH, not including the number of days between the date on the written notice of CBH’s First Level Complaint decision or Grievance decision and the date you asked for a Fair Hearing.

If you requested a Fair Hearing because CBH did not tell you its decision about a Complaint or Grievance you told CBH about within 30 days from when CBH got your Complaint or Grievance, your Fair Hearing will be decided within 90 days from when you filed your Complaint or Grievance with CBH, not including the number of days between the date on the notice telling you that CBH failed to timely decide your Complaint or Grievance and the date you asked for a Fair Hearing.

DHS will send you the decision in writing and tell you what to do if you do not like the decision.

If your Fair Hearing is not decided within 90 days from the date the Department of Human Services receives your request, CBH must comply with the requirements of 55 Pa. Code 275.4 regarding the provision of interim assistance upon the request for such by the Member.

If you have been getting the services that are being reduced, changed, or denied and you ask for an external Grievance review or a Fair Hearing, you must ask for an external review verbally or in a letter that is postmarked or hand-delivered within one day of the date on the notice telling you CBH’s Grievance decision that acute inpatient services you have been receiving are being reduced, changed, or denied or within 15 days of the date on the notice telling you CBH’s Grievance decision that any other services you have been receiving are being reduced, changed, or denied, the services will continue until a decision is made. If you ask for both an external review and a Fair Hearing, you must ask for both within one business day if the services are acute inpatient; for all other levels of care, you must ask for both 15 days from the date on this notice. If you wait to ask for a Fair Hearing until after you receive a decision on your external Grievance, services will not continue.

If your doctor believes that waiting the usual time frame for deciding a Fair Hearing could harm your health, you may ask that the Fair Hearing take place more quickly. This is called an expedited Fair Hearing. You can ask for an early decision by calling DHS at 1-877-356-5355 or by faxing a letter to 717-772-7827. Your doctor must fax a signed letter to this number explaining why taking the usual amount of time to decide your Fair Hearing could harm your health. If your doctor does not send a letter, your doctor must testify at the Fair Hearing to explain why taking the usual amount of time to decide your Fair Hearing could harm your health.

The Bureau of Hearings and Appeals will schedule a telephone hearing and will tell you its decision within three business days after you asked for a Fair Hearing.

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 the Fair Hearing will be decided using the usual time frame for deciding a Fair Hearing.

You may contact CBH Member Services if you need help or have questions about Fair Hearings. You can also contact:

• Pennsylvania Legal Aid Network,
• Community Legal Services, or
• Pennsylvania Health Law Project