Problem Resolution Process

Below you will find information regarding the grievance, appeal and state fair hearing processes, as well as how to request a second opinion and change providers. For questions contact Member Services: Access & Referral at 909.386.8256.

Grievance, Appeal, Expedited Appeal, and State Fair Hearing Processes Brochure (in English and Español)

Change of Provider Request

As a consumer of Department of Behavioral Health, you have the right to request a change if you are not satisfied with your current service provider. Requesting a change of provider does not put you at risk of being denied behavioral health services or having the type of services you received changed. Please fill out the form and turn it into the receptionist at the clinic where you are currently receiving services.

Change of Provider Request Form
Formulario para Solicitar el Cambio de Proveedor

Grievance Process

A grievance is an oral or written expression of your dissatisfaction about any matter other than an Action (see the Action section for more information). You have the right to make a grievance about any aspect of your treatment at a clinic or by a Medi-Cal Fee-For-Service Provider (private psychiatrist, psychologist, LCSW, or LMFT). You may make a grievance verbally or in writing. Grievance forms are available below or in provider/clinic lobbies. Grievances will be processed within 60 days, with the option of a 14 day extension if extending the deadline will be in your best interest. For questions contact Member Services: Access & Referral at 909.386.8256.

Grievance Form
Formulario de Quejas

To file a grievance, fill out the form and mail it to:
Member Services: Access & Referral
303 E. Vanderbilt Way
San Bernardino, CA 92415

Appeal Process

You also have the right to appeal an “Action” taken by the County’s Mental Health Plan.

An “Action” is defined as:
1. Denial, or limiting, of an authorization of a requested service, including the type or level of service;
2. Reducing, suspending, or terminating a previously authorized service;
3. Denial, in whole or in part, of payment for a service;
4. Failing to provide services in a timely manner, as determined by the Mental Health Plan or;
5. Failing to act within the time frames for disposition of standard Grievances, the resolution of standard
Action Appeals, or the resolution of expedited Action Appeals.

Notices of Action and Appeal Forms

Notice of Action – A (Assessment) Form: The NOA-A (Assessment) form is used when the Mental Health Plan or its provider assesses a Medi-Cal beneficiary and determines that the beneficiary does not meet medical necessity criteria and no specialty mental health services will be provided. The NOA-A form was modified to include information regarding appeals and expedited appeals.

Assessment: NOA-A
Evaluación: NOA-A

Notice of Action – B (Denial of Services) Form: The NOA-B (Denial of Services) form is used when a provider requests payment authorization for a specialty mental health service in which the Mental Health Plan denies or modifies the provider’s request and the beneficiary did not receive the service. The NOA-B form was modified to include information regarding appeals and expedited appeals.

Denial of Services: NOA-B
Negado por el Servicios: NOA-B

Notice of Action – C (Post-Service Denial) Form: The NOA-C (Post-Service Denials) form is used when a provider requests payment authorization for a specialty mental health service and the Mental Health Plan denies or modifies the provider’s request and the beneficiary already received the service. This is a new form that reads “this is not a bill” so that the beneficiary knows that s/he is not responsible for the cost of the service rendered but retrospectively denied or modified.

Post-Service Denial of Payment: NOA-C
Denegación de Pago Despues de Servicio: NOA-C

Notice of Action – D (Delayed Grievance/Appeal Decision) Form: The NOA-D (Delayed Grievance/Appeal Decisions) is a new form to be used when the Mental Health Plan does not provide the resolution of a grievance, appeal, or expedited appeal within the required time frames.

Delayed Grievance/Appeal Decision: NOA-D
Demoras en Proceso de Queja/Apelaciόn: NOA-D

Notice of Action – E (Lack of Timely Services) Form: The NOA-E (Lack of Timely Services) is a new form to be used when the Mental Health Plan does not provide services in a timely manner according to their own standards for timely services.

Lack of Timely Services: NOA-E
Falta De Servicio Oportuno: NOA-E

Notice of Action – Back Form: The NOA-Back is the backside of all NOA forms and was modified to include information about appeals, expedited appeals, and expedited SFHs, and delete references to grievances.

NOA-Backside
NOA-Trasero

Appeal Form
An appeal is an oral or written request for review of an Action (as defined). An oral appeal must be followed up in writing. Action Appeal Forms are available below, in the waiting room of the clinic, or the Fee-For-Service Provider. Standard appeals are processed within 45 days, with the option of a 14 day extension if extending the deadline will be in your best interest. Expedited Action Appeals may be requested if you or your provider certifies that taking the time for a standard action appeal resolution could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function. Expedited Appeals are processed within 3 working days. For questions contact Member Services: Access & Referral at 909.386.8256.

Action Appeal Form
Formulario de Acciόn de Apelaciόn

To file an appeal, fill out the form and mail it to:
Member Services: Access & Referral
303 E. Vanderbilt Way
San Bernardino, CA 92415

Second Opinion Request

The Mental Health Plan (MHP) will provide a second opinion by a licensed mental health professional employed by, contracting with or otherwise made available by the MHP when the MHP or its providers determine that the medical necessity criteria have not been met and that the beneficiary is, therefore, not entitled to any specialty mental health services from the MHP. The MHP shall determine whether the second opinion requires a face-to-face encounter with the beneficiary.

Request for Second Opinion Form
Petición de Una Segunda Opinion

State Fair Hearing Process

After the appeals process is exhausted you may file for a State Fair Hearing if you are not satisfied with the outcome of the appeal process. In most cases you have 90 days to ask for a hearing. You may verbally or in writing file for a State Fair Hearing after the exhaustion of an Action Appeal or Expedited Action Appeal process, whether or not you have received a Notice of Action.

State Fair Hearing Rights Poster (in English and Español)

State Fair Hearings may be requested by:
Mail:
California Department of Social Services
P.O. Box 944243, Mail Station 19-37
Sacramento, CA 94244-2430

Phone:
800.952.5253

Fax:
916.229.4110