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The Pennsylvania

Introduction

As of July 1999, most people on Medical Assistance in Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland will have been enrolled in a new health program called "HealthChoices". Under HealthChoices, mental health and substance abuse services (called "behavioral health" services) will be provided separately from physical health services. Physical health services and medications (including meds prescribed by a psychiatrist) will be provided through HMOs (consumers will have the choice of Best, Gateway or MedPlus). Behavioral health services for people living in Allegheny County will be provided through an organization called Community Care Behavioral Health ("CCBH"). Behavioral health services for people living in the other 9 counties listed above will be provided through a company called Value Behavioral Health ("Value").

CCBH and Value will be responsible for ensuring that consumers have timely access to qualified psychologists, psychiatrists, therapists, partial programs, residential (non-hospital) treatment facilities ("RTFs"), wraparound ("Type 50") agencies and other mental health and substance abuse treatment providers. They will also be responsible for making decisions about the type and amount and duration of behavioral health services consumers receive. Consumers have certain appeal rights should they have disputes with CCBH or Value regarding access to providers, the type, amount, duration or quality of behavioral health services CCBH or Value have approved. This document tries to summarize those appeal rights and give consumers and their families practical suggestions in exercising their appeal rights.
 
 

Basic principles

If CCBH (in Allegheny Co.), Value Behavioral Health (in the other counties) or your County MH/MR Agency decides you don't need a particular service or treatment and your psychologist or psychiatrist believes you do, you have the right to appeal. You can appeal to CCBH or Value (depending on your county), to DPW or both.

If you had been receiving the service before CCBH or Value decides you no longer need it and you appeal in time, CCBH or Value must continue to pay for that service until your appeal is decided.

If the pharmacist tells you your HealthChoices HMO won't cover the medication your psychiatrist has prescribed (meds are covered by your HMO- not CCBH or Value), the HMO must pay for a 72 hour supply of the prescribed medication to hold you over while they decide whether they will make a special exception. If the HMO later decides not to make a special exception, you can appeal.

Practical tips for dealing with CCBH, Value or your HealthChoices HMO

Make sure you know where your psychologist, psychiatrist or therapist stands on the service or medication you are seeking. If CCBH or Value (or, for meds, your HMO) is questioning that service, make sure the professional that prescribed or recommended the service is willing to "stick by their guns" even if CCBH, Value (or your HMO) disputes it.

If you don't have confidence in the psychologist or psychiatrist you have through your provider agency, you can ask CCBH or Value for the name of another. They must have at least one other psychologist or psychiatrist who participates in their plan within a 30 minute drive from your home if you live in an urban area, or within a 60 minute drive from your home if you live in a rural area. You will not be able to get CCBH or Value to approve the services you need if the psychologist or psychiatrist that does the eval is not willing to support what you need and not give in to pressure from CCBH, Value or the provider. If you have the means to pay for your psych eval, that is even better as it gives you the ability to get a psych eval from someone that is not dependent on CCBH or Value for most of his or her business and so won't be influenced by financial considerations. You do not have to get the psych eval from a psychologist that has a contract with CCBH or Value so long as you are willing to pay for it yourself. However, CCBH or Value can insist you go to a psychologist or psychiatrist under contract to them to review the recommendations of your psychologist. If CCBH or Value denies coverage of services recommended by your psychologist based on the recommendations of their psychologist, they must still give you written notice and you have the right to appeal.
 
 

When you attend a meeting with providers & CCBH or Value (such as an Interagency Team Meeting), bring someone with you that you trust (you have that right).

It will give you moral support, help you feel less intimidated, give you instant access to another opinion and give you a witness should there be a dispute later on as to what was said or agreed upon.
 
 

If you agree with the services recommended by the psychologist in his or her eval, insist that the provider submit the request for services to CCBH or Value without reducing them, even if CCBH or Value threatens to deny or cut the request.

You have appeal rights if CCBH or Value cuts or denies the request. You do not have appeal rights if you give consent to the provider to reduce the request.
 
 

Read any notices you receive from CCBH or Value, your HMO or your provider carefully. Many notices include important information regarding your appeal rights. Keep all documents!

If you have questions or concerns, call the Health Law Project at 1-412-434-5779 or 1-800-931-7457.

Other Important Phone Numbers

Value Behavioral Health of PA, Inc.

Armstrong 1-877-688-5969

Beaver 1-877-688-5970

Butler 1-877-688-5971

Fayette 1-877-688-5972

Greene 1-877-699-5973

Indiana 1-877-688-5974
 
 

Lawrence 1-877-688-5975

Washington 1-877-688-5976

Westmoreland 1-877-688-5977

Community Care Behavioral Health, Inc.

Allegheny 1-800-553-7499

Medications

For people who are on MA under a category that includes prescription drug coverage, meds prescribed by a psychiatrist will be covered through the physical health HMO the individual chooses (Best, Gateway, or MedPlus). These HMOs will not cover every medication although they are required to cover every type of drug. If your psychiatrist prescribes a drug that the HMO does not cover, you have the following rights.
 
 

Right to find out whether a specific drug you are taking (or expect to take) is covered by the 3 HealthChoices HMOs, before you sign up.

Under a new State law, Act 68, you will be able to find out if a specific drug is covered by an HMO, even if you have not yet signed up with that HMO, by submitting your request in writing to that HMO.

Right to 72 hours worth of meds & to request exception

If the medication prescribed by your psychiatrist is not covered by the HMO you sign up with, the pharmacist will usually call your psychiatrist to see if it is ok to switch you to another drug that the HMO covers. If your psychiatrist believes you cannot be safely switched to another drug, he or she has the right to request a special exception on grounds of medical necessity from the HMO's pharmacy benefits management company. The HMO (or its pharmacy benefits management contractor) is required to make a decision on the request for a special exception in one working day. In the meantime, the HMO is required to pay for 72 hours worth of the prescription. This requirement is found in the Department of Public Welfare’s HealthChoices Request for Proposals RFP#10-97 at Part IV-4 A3 (p. 46). A pharmacist cannot switch you to another drug without your psychiatrist's approval (except for generic substitutions).

If the pharmacist cannot reach your psychiatrist when you come in to have your prescription filled, the pharmacist should still provide you with 72 hours worth of the prescription. In the meantime, you will need to contact your psychiatrist and ask him or her to call your HMO’s pharmacy benefits management company (ask the pharmacist for the phone number) so your psychiatrist can explain to them why you need that particular medication or can prescribe a different med if he or she believes that would be ok.

HMOs may require that prescriptions for drugs that are on their list of covered medications (called the "formulary") be approved by their pharmacy benefits contractor before the prescription is filled. In those instances where the pharmacist cannot get through to the pharmacy benefits contractor or get an immediate answer from them, your HMO is required to pay for a 72 hours supply of the medication.
 
 

Right to appeal if special exception request or prior approval request is denied

You have the right to appeal by filing a "grievance" in writing with the HMO. The HMO cannot require that you file it with their pharmacy benefits contractor. However, filing the grievance will not automatically get you the prescription, until and unless you win your grievance. You also have the right to file an appeal with DPW.
 
 

Right to continue to get a previously approved med while appealing

If your HMO refuses to cover a medication they had previously approved for you as part of "ongoing treatment", you are entitled to appeal that denial, either by sending a "grievance" to the HMO or sending a "Request for a Fair Hearing" to DPW. If you appeal the denial (either with the HMO or DPW) within 10 days from the date the HMO tells you they won’t cover the med any more, the HMO must continue to pay for that medication until your appeal is decided.

Phone Numbers for HMOs

Best Health Plan

Member Services

1-800-286-4242

(TTY/TTD 1-800-361-2629)

Provider Services

1-800-699-3627

Gateway Health Plan

Member Services

1-800-392-1147

(TTY/TTD 1-800-654-5988)

Provider Services

1-800-392-1145

MedPLUS+ Health Plan

Member Services

1-800-414-9025

(TTD/TTY 1-800-616-0021)

Provider Services

1-800-600-9007
 
 
 
 

Denials or reductions in Wraparound Services, Summer Therapeutic Activities or payment for a Residential Treatment Facility for persons under 21 ("Impartial review")

"Wraparound" are those one-on-one services most commonly provided in a child’s home or school. Therapeutic staff support and mobile therapy are the most common forms of wraparound. Summer therapeutic activities programs are the special therapeutic summer camps.

If your child’s behavioral health contractor (CCBH or Value) decides it does not want to provide (or continue to provide) the number of hours of wraparound recommended in your child’s most recent psychiatric or psychological evaluation or does not want to cover summer therapeutic activities programs, before it can deny the service or reduce the hours, it must send all the relevant documentation to the State Office of Mental Health & Substance Abuse Services for an "impartial review". CCBH or Value cannot reduce hours of wraparound while the "impartial review" process is going on. CCBH or Value must send in the documentation "within 10 working days of receiving the request for mental health wraparound services". The Office of Mental Health & Substance Abuse Services will send the documentation to a child psychiatrist with whom they have a contract. Families should make sure that CCBH or Value has all the documentation that shows their child’s need for the service being requested. Families should not rely entirely on their "Type 50" provider to submit all the useful documentation. Families should follow up with CCBH or Value to make sure they have all the relevant documentation and to insist they send it all in.

The reviewing psychiatrist has 18 days from the date the request was made to CCBH or Value to complete his/her review. However, in cases where wraparound is already being provided, CCBH or Value may reauthorize services for a month while they are awaiting a decision from the reviewing psychiatrist. This is called an "administrative reauthorization". The reviewing psychiatrist informs CCBH or Value of his/her decision. If the reviewing psychiatrist determines that the behavioral health firm was wrong, the behavioral health firm must approve the number of hours (or days of summer program) that they reviewing psychiatrist deemed appropriate. If the reviewing psychiatrist agrees with CCBH or Value, CCBH or Value must send a written notice to the family within 21 days of the date the request for services or continuation of services was made to CCBH or Value. The family can then appeal as set out on the following pages.

[Behavioral health contractors are required to comply with these "impartial review" requirements under Appendix H, Part II, I of the HealthChoices Behavioral Health Request for Proposals, RFP 11-97. Contact us if you would like a copy of "Protocol for Impartial Review".]
 
 

Refusals to reauthorize Ongoing Services (adults & children)

If CCBH or Value refuses to reauthorize (reapprove) a service the individual has been receiving and which was being paid for with Medical Assistance funds, the consumer or family has the right to file an appeal with the Department of Public Welfare and/or CCBH or Value. The consumer or family can also appeal if CCBH or Value reauthorizes the service in a lesser amount (# of hours or visits) or different level (i.e., TSS instead of Mobile Therapist). If an appeal is made (either with DPW or a "grievance" with CCBH or Value) within 10 days from the date CCBH or Value notifies the consumer or family of the refusal to reauthorize (or before the end date of the previous authorization if the service had been authorized for less than 10 days), CCBH or Value must continue paying for the service until the appeal or grievance has been decided or until the end of the period of service being requested, whichever comes sooner!

This continued payment requirement applies even if the services currently being received were authorized by DPW rather than CCBH or Value (under the old "fee for service" system). However, CCBH or Value may have the right to seek reimbursement from the consumer or family if they lose their appeal (although we have not yet seen this happen). The consumer or family can file an appeal with DPW up to 30 days after the refusal to reauthorize but payment for services will not be continued during the appeal if it is filed more than 10 days after the denial

Denials of emergency or "urgent" services where the consumer is not already receiving the service (adults & children)

Where CCBH or Value denies authorization for emergency or urgent services that the consumer is not already receiving and the consumer, family or provider files a "grievance" with CCBH or Value (as explained in the following pages), the contractor must have a process for an "expedited reconsideration" of the determination. The consumer or family can make an appeal/grievance verbally or over the phone when it involves an emergency or urgent situation. CCBH or Value must make a decision on this appeal within 24 hours!

Definition of urgent: "Any illness or severe condition which under reasonable standards of medical practice would be diagnosed and treated within a twenty-four (24) hour period and if left untreated, could rapidly become a crisis or emergency situation. Additionally, it includes situations such as when a person's discharge from a hospital will be delayed until services are approved or a person's ability to avoid hospitalization depends upon prompt approval of services. " [from p. xiv of RFP-11-97]

Help from DPW: If the MCO fails to comply with the timelines set out above, the consumer or family can contact the Office of Mental Health's Grievance & Appeals division at (717) 772-7862.
 
 

Appeals ("grievances") to CCBH, Value or your HMO

If CCBH, Value or your HMO refuse to cover or pay for a service or medication on grounds that it is not medically necessary and you appeal to them, your appeal is called a "grievance".

Filing grievances with the contractor (1^st level grievances)

A grievance must be in writing (except in an emergency or urgent situation). However, the contractor has a responsibility to offer assistance to consumers/families in writing up grievances. The consumer should write "Grievance" at the top of the written grievance. The grievance should also request specific corrective action.

The grievance should be sent to the contractor within 30 days of the date of the denial notice from the contractor. Appeals regarding issues other than denials of service based on lack of medical necessity and appropriateness are now called "complaints" under a new state law, Act 68. "Complaints" would include appeals to CCBH or Value involving issues like delays in obtaining services that have been authorized or poor quality services. However, they follow the same basic process as explained below.

How does a 1^st level grievance work?

A 1^st level grievance is basically an internal review by staff of CCBH or Value of the denial and any documentation submitted by the consumer or provider. Unlike a DPW appeal, the consumer does not have the right to appear in person or over the phone.

Who decides the 1^st level grievance?

Where the denial is on clinical grounds (e.g. lack of medical necessity), the contractor staff deciding the 1^st level grievance must "have the necessary orientation, clinical training and experience to make an informed and impartial determination...." [Page 2, Appendix H of RFP 11-97] Denials of inpatient care must be approved by a physician (psychiatrist). The staff deciding the 1^st level grievance must be different than the staff that made the decision being appealed.

How quickly must the decision be made on the 1^st level grievance?

If the adult consumer or family appeals a denial of routine services (where the consumer is not in an emergency or urgent situation) by CCBH or Value, the contractor must make a decision on the appeal within 5 working days. The decision must be provided, in writing, to the consumer (or family for a child).

What if you lose your 1^st level grievance? (2^nd level grievances)

The consumer or family may file a "2^nd level" grievance if they lose at the 1^st level. CCBH or Value may place time limits on how long the consumer has to file the 2^nd level grievance from the date of the 1^st level grievance decision. The 2^nd level grievance must also be filed in writing. If the consumer loses the appeal/grievance, he/she can file a 2^nd level grievance and if filed within 10 days, the contractor must reinstate the services until the 2^nd level grievance is decided or until the requested period of service is up. It is likely that a consumer will get a decision from the 1^st and 2^nd level grievances before they get a decision from their DPW appeal. If the consumer is satisfied with the outcome of the 1^st or 2^nd level grievance, he or she can withdraw their DPW appeal by writing a letter to the address listed above or to the DPW Hearing Officer, if one has been assigned. If the consumer is not satisfied with the outcome of the 1^st or 2^nd level grievance, he or she should continue with the DPW appeal.

How does a 2^nd level grievance work?

The consumer/family has the right to appear in person at the 2^nd level grievance. The consumer also has the right to be represented by anyone of their choice. They also have the right to present witnesses and documents. They also have the right to question anyone testifying on behalf of CCBH or Value.

Who decides the 2^nd level grievance? Second level grievances are decided by a "Grievance Committee" comprised of persons not involved either in the original denial or in the decision on the 1^st level grievance. At least one member of the Grievance Committee must be a consumer.

How quickly must the decision be made on the 2^nd level grievance? The written hearing decision must be sent to the consumer within 30 days of the date the 2^nd level grievance was filed with CCBH or Value or within 10 working days of the grievance hearing.

What if you lose your 2^nd level grievance? [appeal to the Dept. of Health]

If the consumer loses the 2^nd level grievance, he or she can file an appeal with the PA Department of Health. This appeal must be made within 15 days of the written 2^nd level grievance decision. Appeals are made by mailing a letter, along with a copy of the 2^nd level grievance decision to:

Bureau of Managed Care, Department of Health

Attention: Grievance Appeals

P. O. Box 90

Harrisburg, Pennsylvania 17108-0090

If it involves an issue of whether a particular service is or was "medically necessary", the Dept. of Health will assign the appeal to a special organization that has been certified to do "utilization review". This organization cannot have any financial connection to CCBH, Value or your HMO (depending on which the appeal is against). It has 60 days to issue a written decision. The decision must be made a physician (psychiatrist) or licensed psychologist.

Appeals to CCBH or Value involving issues like delays in obtaining services that have been authorized or poor quality services are called "complaints". Note that if your are appealing the denial of an appeal that had been classified as a "complaint" by Value, CCBH or your HMO, your appeal goes to:

Write a short letter with the word "appeal" at the top. Include:

• the consumer's name, address and telephone number
• the consumer's Medical Assistance recipient ID number (off the yellow Access card)
• the name of CCBH or Value
• the case number, if any, assigned to the consumer by CCBH or Value
• the specific service that was denied or approved in a lesser amount with dates, if applicable
• the reasons why you disagree with the denial
• a request for continuing payment of services (if applicable)
• if you want to have a hearing in person, rather than over the phone, state that in the letter (but be prepared to go to the State Office Building in Pittsburgh)
• the signature of the consumer (or parent or legal guardian for children)

Mail the appeal to:

First of all, a notice of the appeal will be sent by the Office of Medical Assistance Programs to CCBH or Value. Upon receipt of that notice, CCBH or Value should continue paying for the service if the appeal was filed within 10 days of the consumer being notified. Next, the Office of Medical Assistance Programs will send the appeal to the Office of Hearings and Appeals. The Office of Hearings and Appeals will send out a postcard that the consumer or family must return or else the Office of Hearings and Appeals will dismiss the appeal.

The consumer has the right, before the hearing, to see the documents kept by CCBH or Value that are relevant to the denial being appealed. The consumer has the choice of having the hearing held at the State Office Building in Pittsburgh or over the phone. In either event, the consumer can be represented by anyone of their choice and can present witnesses and cross examine (ask questions of) people who testify for CCBH or Value. After the hearing, a written hearing decision will be sent to the consumer. If the consumer loses, he/she may request "reconsideration" of the hearing decision by the Secretary of Public Welfare within 15 days of the date of the hearing decision which will postpone the hearing decision from going into effect until the Request for Reconsideration is decided. Currently, it is taking several months for Requests for Reconsideration to be decided.
 

Denials of non-urgent services where the consumer is not already receiving the service (adults & children)

Appeals to DPW

The consumer (or family for a child) can also file an appeal with DPW as set out above in the section entitled "Refusals to reauthorize ongoing services". The consumer may file an appeal with DPW at the same time they file a grievance with CCBH or Value, or just an appeal with DPW or just a grievance. If the consumer wins either one, he or she just withdraws the their appeal or grievance (in writing).

The consumer has 30 days from the initial denial to file an appeal with DPW. If the consumer files a grievance with CCBH or Value first, the consumer can still file an appeal with DPW within 30 days of the contractor’s decision on the grievance or within 30 days of the contractor’s decision on the 2^nd level grievance. However, filing an appeal with DPW does not require CCBH or Value to pay for the service pending the appeal decision where the appeal involves a service the consumer was not already receiving. If it takes longer than 90 days from the date the appeal is filed with DPW, the consumer or family is entitled to get "interim assistance". Under "interim assistance", DPW must start paying for an ongoing service if that is the subject of the appeal. They must continue to pay until the hearing decision is rendered. Interim assistance does not apply to appeals regarding payment for services that have already been provided.

DPW appeals entitle the consumer/family to a hearing which is either held over the telephone, or at the consumer’s request, in person at the State Office Building in Pittsburgh.

Drafted 6-22-99

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