1 / 17

Responding Successfully to a Denial of Service

Responding Successfully to a Denial of Service. Hint: Time is on your side. The Grievance & Appeal process. 1 st level grievance (2 nd opinion) 2 nd level grievance (Panel review) 3 rd level grievance (Health Dept) 4 th level grievance ( DPW Fair Hearing)

josiah-wood
Télécharger la présentation

Responding Successfully to a Denial of Service

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Responding Successfully to a Denial of Service Hint: Time is on your side.

  2. The Grievance & Appeal process • 1st level grievance (2nd opinion) • 2nd level grievance (Panel review) • 3rd level grievance (Health Dept) • 4th level grievance (DPW Fair Hearing) • 5th level grievance (CMS appeal) (An authorization runs 120 days)

  3. 1st level grievance:The MCO “second opinion” • 8 or 9 days after the date on your first Denial of Service letter, request a 1st level grievance. • This keeps the same level of service going during the grievance process. 10

  4. 1st level grievance:The MCO “second opinion” • A second MCO reviewer looks over the first MCO reviewer’s work, to see if they agree or disagree (they rarely disagree). • This keeps the same level of service going during the grievance process. 15

  5. 2nd level grievance:The MCO “Panel Review” • 8 or 9 days after receiving the 2nd Denial of Service letter, request an appeal of the decision. • This keeps the same level of service going during the appeal process. 25

  6. 2nd level grievance:The MCO “Panel Review” • Ask to be included in the appeal meeting, and request the meeting to be held 20 days after the date of your appeal request. • This keeps the same level of service going during the appeal process. 50

  7. 3rd level grievance:The Health Department review • 8 or 9 days after the date on your second Denial of Service letter, request a 3rd level grievance. • This keeps the same level of service going during the grievance process. 65

  8. 3rd level grievance:The Health Department review • Ask to be included in the appeal meeting, and request the meeting to be held 20 days after the date of your appeal request. • This keeps the same level of service going during the appeal process. 90

  9. 4th level grievance:The DPW “fair hearing” • 8 or 9 days after the date on your second Denial of Service letter, request a 3rd level grievance. • This keeps the same level of service going during the grievance process. 100

  10. 4th level grievance:The DPW “fair hearing” • Ask to be included in the appeal meeting, and request the meeting to be held 20 days after the date of your appeal request. • This keeps the same level of service going during the appeal process. 125

  11. Win or Lose • Your child wins. Auth ends @ 120 days Days in appeal: 125

  12. The Absolute Basics • A life-domainpsychological evaluation is absolutely necessary. • A good Behavior Specialist Consultant is indispensible. • Neither is of any use without DATA.

  13. Documenting what is necessary • Dangerous to self or others? • Destructive to property of substantial value? • Severely disruptive to own or others’ lives?

  14. Documenting what is necessary • Frequency (how often does it happen?) • Intensity (how severe is it?) • Duration(how long has it been going on or how long do typical episodes last?)

  15. Documenting what is necessary • Evidence of Collaboration • Pediatrician or Psychiatrist involvement • School involvement and active support • Home and Community supports available • Thorough and complete Treatment Plan

  16. Competent professionals do more than give opinions… • They know the “rules” that the MCOs operate under and, • They do what is necessary to get their treatment recommendations implemented.

  17. Thank you. John Cappo Clinical Coordinator The Institute for Behavior Change www.ibc-pa.org

More Related