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 contractorís decision on the grievance or within 30 days of the contractorís decision on the 2nd 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 consumerís request, in person at the State Office Building in Pittsburgh.

Drafted 6-22-99