Grievances and complaints procedures

AZ | AZBH | CA | CO | CT | DE | DC | FL | FLMH | HI | HIBH | IL | IN | IA | IABH | KS | KY
ME | MD | MA | MABH | MI | MN | MO | MT | NE | NEBH | NV | NH | NJ | NM | NY | NC | ND
OH | OK | ORMH | PA | PABH | RI | SC | TN | TX | UT | UTMH | VA | WA | WV | WI

"8. MEMBER INFORMATION...
The Contractor shall produce and provide the following printed information to each member or family within 10 days of receipt notification of the enrollment date:
I. A Member Handbook which, at a minimum, should include the following items that are also listed in the Office of Managed Care, Operations Policy #404, Member Information Policy: ...
s. Grievance procedures, including a clear explanation of the member's right to file a grievance and to appeal any decision that affects the member's receipt of covered services." Arizona Contract, pages 21-22.

AZBH

"MEMBER HANDBOOK AND PROVIDER MANUAL...
At a minimum the member handbook shall include: ...
j. Grievance procedures including a clear explanation of the member's right to file a grievance and to appeal any decision that affects the members receipt of covered services...
l. Specific information regarding how members can have questions answered, problems resolved, complaints addressed, i.e., how to access the member advocate or ombudsperson, including telephone numbers." Arizona Behavioral Contract, page 13.

"GRIEVANCE SYSTEM...
ADHS must ensure. that Member Handbooks and Provider Manuals advise members and providers of grievance and appeal rights, and that non-contracting providers are notified of their grievance and appeal rights." Arizona Behavioral Health Contract, page 33.

"ATTACHMENT F
GRIEVANCE PROCESS AND STANDARDS
The ADHS grievance policy, at a minimum, must include, but is not limited to, the following standards: ...
B. The grievance procedure shall be provided to a member upon enrollment with ADHS and to all RBHAs and their providers at the time of contract." Arizona Behavioral Health Contract, Attachment F, page 1.

"6.5.6.2 Written Policy: Member Rights
The Contractor's written policy regarding Member rights will include the Member's right to be treated with respect..., to voice Grievances about the organization or the care received... the right to request a fair hearing." California Contract, page 96.

"6.9.5 Membership Services Guide
Contractor shall develop and distribute a Membership Services Guide that includes the following information: ...
L. Procedures for filing a complaint/Grievance, including procedures for appealing decisions regarding Member's coverage, benefits, or relationship to the organization. Include the title, address, and telephone number of the person responsible for processing and resolving complaints/Grievances...

N. Information on the Member's right to the Medi-Cal fair hearing process regardless of whether or not a complaint/Grievance has been submitted or if the complaint/Grievance has been resolved, pursuant to Title 22, CCR, Section 53452, when a health care service requested by the Member or provider has been denied, deferred or modified. The State Department of Social Services' Public Inquiry and Response Unit toll free telephone number (800) 952-5253...

U. Information on how to access State resources for investigation and resolution of Member complaints, including the DHS Medi-Cal Managed Care Ombudsman toll-free telephone number (1-888-452-8609) and the DOC HMO Consumer Service toll-free telephone number (1-800-400-0815)." California Contract, pages 136-137.

"EXHIBIT E
MEMBER HANDBOOK REQUIREMENTS
To inform Members of their rights and responsibilities, the Plan shall publish and distribute to all Members a Member Handbook that shall include but is not limited to the following information: ...
12. Complaint Form...
2. Informal and formal procedures to voice a complaint and file a grievance related to coverage, benefits, or any aspect of the Member's relationships to the Contractor through both the Contractor's internal grievance process and the Department's or the State's external process(es)." Colorado Contract, Exhibit E, page 1.

"3.28 Services to Members...
b. The MCO shall mail the Member handbook and provider directory to Members within one week of enrollment notification. The Member handbook shall address and explain, at a minimum, the following: ...
4. the MCO's grievance and the DEPARTMENT's fair hearing processes..." Connecticut Contract, page 38.

"6.2 Grievance and Fair Hearing Process.
d. The MCO must clearly specify in its Member handbook/packet the procedural steps and timeframes for filing a grievance and fair hearing request, including the timeframe for maintaining benefits pending the conclusion of the grievance and fair hearing process. The Member handbook/packet shall include at least one (1) grievance/request for fair hearing form and an envelope bearing the address at the DEPARTMENT to which grievances must be sent." Connecticut Contract, page 76.

"11.5 MCO Member Services
5.1 New Member Orientation
The MCO must have written policies and procedures for orienting new members about the following: ...
(e) How to register a complaint or file a grievance." Delaware RFP, page II.14.

"5.10.2 Member Handbook Minimum Contents
The member handbook shall follow QARI standard X.D. (`Enrollee Rights and Responsibilities, Communication of Policies to Enrollees/Members') for the minimum level of information to be communicated. QARI standards can be found in Appendix G. The handbook shall include: ...
(h) How to register a complaint with the plan or file a formal grievance." Delaware RFP, pages II.20-II.21.

"11.4 Consumer Notification
The MCO will inform members of their right to grieve/appeal and of the grievance/appeal procedures. The MCO must:

(a) Inform the member about rights as a member of MCO services; this will include informing the member both orally and in a clearly written format in the member's own language about both the MCO and State grievance procedures; if the member has an auditory and/or visual impairment, reasonable accommodations must be made to assure that the
member is informed and understands his/her rights

(b) Include in its information a toll-free number for a member to use to communicate a grievance/appeal

(c) Provide information:
1. In no less than one (1) conspicuous location of each reception area of each provider within the MCO
2. At the time of initial enrollment
3. Each time a service is denied, reduced, and/or terminated; denial includes any instance in which a specific request for service has been made in which the member has been told `no'
4. Any time the MCO denies or reduces a service, e.g. Private Duty nursing or home Health care, the member must be given adequate notification in writing and services must be continued at existing levels, if the case is appealed, until all appeals are resolved.
5. Each time the member enrolls in another MCO as a result of a transfer or re-enrollment
6. Each time the grievance/appeal methods and procedures. are substantially changed

(d) Give members due process rights when it denies, reduces, or terminates a member's health service or asks the State to transfer him/her; it must notify the member or his/her authorized representative in writing of the right to file a grievance/appeal; the notice shall explain:
1. How to file a grievance/appeal with the MCO
2. How to file a grievance/appeal with the State
3. That filing or resolving a grievance/appeal through the MCO's grievance process is not a prerequisite to filing for a State hearing
4. The circumstances under which health services will be continued pending a grievance/appeal
5. Any right to request an expedited grievance/appeal
6. The right to be advised or represented by an ombudsman, lay advocate, or attorney
7. The right to request that a disinterested third party who works for the MCO assist in the writing of the grievance/appeal

(e) Inform the member of the time frame in which a grievance/appeal will be heard

(f) Inform the member in writing of the results of the Hearing; at a minimum, this notice will include all of the information shown in 11.4(d)." Delaware RFP, pages II.64-II.65.

"4. Evidence of coverage
a. Within ten (10) business days of the date on which the District notifies Provider that an individual has been enrolled with Provider, Provider shall issue to each enrollee the following:
(2) a Member Handbook written at the 5th grade reading level and containing at a minimum the following information:
(g) an explanation of Provider's complaint and grievance process and telephone numbers for complaints and inquiries...
[(i)] an explanation of the enrollee's right to complain, grieve or appeal to the District and the Office of Fair Hearings..." District of Columbia Contract, pages 16-18.

"26. Grievance System Requirements...
f. Procedural steps must be clearly specified in the member handbook for members and the provider manual for providers, including the address, telephone number and office hours of the grievance coordinator." Florida Contract, pages 46-47.

"18. Member Notification...
a. Prior to, or upon enrollment, the plan shall provide the following information to all new members of the plan:
...a member services handbook...
(a) The member services handbook shall include the following information: ... Grievance procedures." Florida Contract, pages 36-37.

"AMENDMENT 001...
2. Attachment I, B.11 is amended to read:
Plan Materials...
C. Title XXI MediKids participating are not eligible to receive Medicaid and therefore are eligible for Medicaid Fair Hearing. The plan shall inform the members in one of the following ways:
* The plan shall provide a welcome letter with the member handbook which explains that MediKids members are precluded from the use of a Medicaid Fair hearing as a grievance option." Florida Contract, Amendment 001, page 1.

FLMH

"2.14 Enrollment ...
5. Upon enrollment, the contractor shall provide the following information to the new enrollee: ...
f. Member Handbook, which shall include the following: ...
(6) Description of grievance procedures." Florida Mental Health RFP, page 37.

"40.450 Responsibilities of the Health Plan...
* Explain the complaint and grievance procedures." Hawaii RFP, page 48.

"48.000 Educational Materials...
48.020 Plan's Responsibilities...
The following is the minimum information to be included in the booklet or pamphlet: ...
* Reporting complaints or grievances
* Availability of mediation services for ABD members." Hawaii RFP, page 77 & Hawaii RFP, Amendment 5.0.

HIBH

"30.900 Other Services to be Provided...
* Member Education.
At a minimum, the plan shall also provide members with information on the procedures which members need to follow related to.filing a grievance...." Hawaii Behavioral Health RFP, page 31.

"40.440 Responsibilities of the BHMC Plan...
The following describes the responsibilities of the BHMC plan upon enrollment of a member...
* Orient and familiarize, then provide each member with a member handbook explains the operations of the plan including the procedures to follow to. file a complaint and grievance procedures, etc..." Hawaii Behavioral Health RFP, page 39.

"48.000 Educational Materials
48.010 DHS Responsibilities
DHS shall develop materials and presentations to educate the members on the: ...
* Appeals process

48.020 Plan's Responsibilities...
The following is the minimum information to be included in the booklet or pamphlet: ...
* Reporting complaints or grievances..." Hawaii Behavioral Health RFP, pages 61-62.

"(11) The Contractor must provide new Beneficiaries with the following materials no later than ten (10) business days following receipt of the Pre-listing:
(A) The Beneficiary handbook in conformance with Article V(w) and a membership packet of information detailing all aspects of the Contractor's Plan, which must include, at a minimum...grievance procedures." Illinois HMO Contract, page 14.

"3.2.4 The Enrollment Process
During the Medicaid enrollment process, Benefit Advocates (BAs) ensure that all Hoosier Healthwise enrollees receive either a face-to-face or telephone interview during which they are educated about the usefulness of primary and preventive care; the differences between Hoosier Healthwise and the traditional Medicaid program; and the PCCM and RBMC delivery systems. During this interview, potential enrollees also typically receive brochures describing the program and watch a video on Hoosier Healthwise. At time of writing this RFP, a process for handling potential Hoosier Healthwise enrollee education at Medicaid application outstations is being developed.

MCOs are required to provide information regarding.grievance procedures, and any other information requested by the
State, for use in potential education and enrollment...

4.6.5.3 Enrollee Education Requirements
The MCO will be responsible for developing and maintaining enrollee education programs designed to provide the enrollees with clear, concise, and accurate information about the MCO's health plan. Enrollee education materials should include, but are not limited to the following:
* An enrollee handbook which describes in full detail the terms and nature of services offered by the MCO, including . grievance procedures... For a complete description of the information that must be included in the enrollee handbook, refer to Chapter 4 of the MCO Procedure Manual and the readiness review criteria located in the Procurement Library." Indiana RFP, pages 3-9, 4-26-4-27.

"4.12 Enrollee Information...
The HMO shall mail an Enrollee handbook to the Enrollee within ten calendar days of enrollment notification to the HMO, which, at a minimum, shall include: ...
- complaint and grievance procedures and procedure to appeal an adverse HMO decision to the Department." Iowa Contract, page 30.

"9.1 HMO Grievance Procedures
The HMO shall:
- provide the Enrollee a written procedure of the HMO's grievance process, including expedited grievances, no later than the effective date of coverage;
- include in the written procedure provided to the Enrollee the identification of a contact person in the HMO to receive and process grievances ." Iowa Contract, page 51.

"STANDARD ENROLLEE HANDBOOK LANGUAGE
Grievance Appeals
As a Medicaid HMO Enrollee, if you are unable to obtain medical care which you believe is necessary for your well being, you should use (HMO Name)'s complaint (grievance) process to solve your complaint. You may request a hearing and appeal of the HMO's decision at any time by writing:
Iowa Department of Human Services
Bureau of Policy Analysis
Appeals Section
Hoover State Office Building - 5th Floor
Des Moines, Iowa 50319." Iowa Contract, page 82.

IABH

"45.3 REVIEW OF NON-CLINICAL DECISIONS...
The complaint/grievance process shall ensure the following: ...
f) That information about complaint/grievance process will be distributed to all enrollees and network providers and that such information will be made available to all others upon request...

48.0 OUTREACH IOWA PLAN ENROLLEES
Within 10 working days of the date enrollee information is provided to the Contractor, the Contractor shall provide the Medicaid enrollee(s) with information about the Iowa Plan.Enrollment information must include: .explanation of clinical review process including the enrollee's right to a fair hearing under 441 Iowa Administrative Code, Chapter 7 and the way in which to access that fair hearing process.explanation of complaint and grievance process." Iowa Behavioral Health Contract, pages 32-33.

"O. MEMBER HANDBOOK.
At a minimum, the member handbook should include: ...
* How to register a complaint with the plan or file a formal grievance.
* The HMO's procedures for appeals." Kansas Contract, pages 21-23.

"B. HMO PROCEDURES
The HMO shall:
* Operate a complaint process, including telephone access, which members can use to make verbal complaints, to ask questions and get problems resolved without going through the formal, written grievance process.
* Have written policies and procedures which detail what the complaint/grievance system is and how it operates. The policy shall include a form for members to use for grievances.
* Inform members about the existence of the formal and informal complaint/grievance processes..." Kansas Contract , pages 57-58.

"Each Partnership shall publish a Member Handbook and make the handbook available to members immediately upon enrollment...
The handbook shall include at least the following information: ...
(t) Procedures for filing a grievance or making a complaint and how to appeal as well as how to request a state fair hearing. This must include the title, address and telephone number of the person responsible for processing and resolving complaints and grievances..." Kentucky RFA, pages 54-55.

"The Partnership shall submit a plan for pre-enrollment education and outreach. The plan should include mailing schedules, materials that will be enclosed and methods for educating Members, advocates and human services providers about the Partnership. Written descriptions should include the following: ...
* The procedures for handling complaints and grievances." Kentucky RFA, pages 80-81.

"3.2 MEMBER SERVICES...
B. ORIENTATION OF NEW MEMBERS

1. Orientation...At a minimum, the description shall include explanations of the following: ...
j. the role of the HMO Advocate;
k. how to file a complaint/grievance; and
I. how to request an administrative hearing.

2. Member Packet. The Contractor shall also provide each Enrollee's household, within five (5) calendar days of an Enrollee's effective date of enrollment, with a member packet, which shall include, at a minimum: ...

c. the member handbook. The handbook shall include, at a minimum, information on: ...
viii. how to contact member services and a description of its function, including the role of the HMO Advocate;
ix. how to file a complaint/grievance;
x. how to request an administrative hearing." Maine Contract, pages 14-15.

".09 Quality Assurance System-General.
Unless an applicant satisfies the requirements of Regulation .08 of this chapter, it shall include in its application the following information or descriptions: .
O. A written description of the applicant's complaint resolution protocol, which shall, at a minimum: ...
(8) Specify how the enrollee will be informed that the enrollee's grievance is being investigated, and the protocols by which grievances will be resolved,
(9) Describe what methods will be used to inform enrollees about the operation of the grievance procedure." Maryland COMAR 10.09.64.09.

"B. An MCO shall, at the time of enrollment and annually thereafter at the time of reassignment. furnish each enrollee with a copy of the MCO's enrollee handbook that includes the following current information pertaining to the county in which the enrollee resides: .
(13) A description of the MCO's consumer services hotline, including toll-free telephone number, explaining how it can be used to obtain information and assistance, and an explanation of the MCO's internal grievance procedure."
Maryland COMAR 10.09.65.02

".02 Internal Grievance Process for Enrollees...
B. An MCO shall: ...
(4) Deliver a copy of the MCO's grievance procedures to each enrollee:
(a) With the MCO's initial mailing to a new enrollee, and
(b) At any time upon an enrollee's request.

C. An MCO shall include in the internal grievance process described in the written grievance procedures the procedures for registering and responding to complaints in a timely fashion, which:
(1) Include a specific standard, monitored by the MCO for compliance, directing that:
(a) Emergency medically related complaints shall be resolved, given the nature of the emergency, in no more than 24 hours,
(b) The decision time for non-emergency medically related complaints may not exceed 5 days, and
(c) For administratively related complaints, the decision time may not exceed 30 days;
(2) Include participation by the provider, if appropriate;
(3) Allow participation by the ombudsman, if appropriate;
(4) Ensure the participation of individuals within the MCO who have the authority to require corrective action;
(5) Require documentation of the substance of the complaints and actions taken...
(7) Include a procedure for immediate notice to the Department of all disputed denials of benefits or services in emergency medical situations;
(8) Include a procedure for notice of all disputed non-emergency medical care denials to the Department within 3 business days of the determination to deny;
(9) Include an appeal process which provides at its final level an opportunity for the enrollee to be heard by the MCO's chief executive officer, or the chief executive officer's designee." Maryland COMAR 10.09.71.02.

"Section 2.3 Enrollment Activities...
B. Enrollment...
2. The Contractor shall: ...
f. Provide new Enrollees with a new member packet, including but not limited to, either a MassHealth Standard or MassHealth Basic member handbook as appropriate...

The member handbook shall include, but not be limited to the following: ...
9) how to voice or submit a Complaint or Grievance, including the Enrollee's ability to contact the assHealth Customer Service Center; and
10) how to file an Appeal of a benefit or coverage decision." Massachusetts Contract, pages 25-27.

MABH

"1.03 Communication
The Contractor shall: ...
1.03.03 Create, maintain, and update educational and informational material regarding... Appeals, complaint, and grievance processes, which shall be submitted to the division for its prior review and approval prior to distribution of this material to any party including, but not limited to, enrollees, Providers, enrollees, family members, and other interested parties." Massachusetts MH/SAP Contract, Appendix B, pages 3-4.

"7.0 Appeals and Grievances
The Contractor shall:
7.01 Maintain written policies and procedures for the filing, receipt, prompt resolution, and documentation of any and all appeals and grievances of service authorization decisions for covered Services brought by enrollees, enrollees' family members, or Providers on behalf of enrollees. such policies and procedures shall be approved by the Division, and include, at a minimum, the following: ...
b. a mechanism for informing enrollees of the appeals and grievance procedures." Massachusetts MH/SAP Contract, Appendix B, page 53.

"II-T MEMBER AND ENROLLEE SERVICES...
3. Member Handbook...
At a minimum the member handbook must include: .
*Information regarding the grievance and complaint process including how to register a complaint with the contractor, and/or the State, and how to file a written grievance
*Information regarding the State's fair hearing process and that access to that process may occur without first going through the contractor's grievance/complaint process." Michigan contract, pages 48-49.

"Section 3.2.3. Enrollment Materials.
A. Enrollment Information. The HEALTH PLAN shall present to all new Enrollees the following information within 15 calendar days of the receipt of readable enrollment data from the STATE.
1) A Certificate of Coverage (COC) that has been prior-approved by the STATE and that will include the following:
a). a description of how Enrollee Complaints are resolved, including the telephone number of the department or person handling Complaints...

6) A description of all Complaint and Appeal rights and procedures available to Enrollees, including the HEALTH PLAN's internal grievance procedures, the availability of arbitration to appeal an internal grievance decision, the ability for internal and STATE appeals to run concurrently, and the availability of a second opinion within the HEALTH PLAN." Minnesota Contract, pages 23-24.

"8.1.5. Changes to Procedure. Any change in the HEALTH PLAN's Copayment procedure shall be consistent with the provisions of Article 8 and is subject to STATE approval. The HEALTH PLAN shall inform Enrollees of all changes in Complaint procedures at least two weeks prior to implementation." Minnesota Contract, page 79.

"Section 8.2. Denial, Termination, or Reduction of Services (DTR) Notice.
Section 8.2.1. Notice Requirements. If the HEALTH PLAN denies, reduces or terminates services or claims that are:
1) requested by an Enrollee,
2) ordered by a Participating Provider,
3) ordered by an approved, non-Participating Provider,
4) ordered by a care manager, or
5) ordered by a court, the HEALTH PLAN must notify the Enrollee in writing of the following: ...

E. An explanation of the Enrollee's right to:
1) file a complaint and/or request an evidentiary hearing with the HEALTH PLAN within 30 days of receipt of the DTR notice,
2) request an evidentiary hearing with the STATE pursuant to Minnesota Statutes, Section 256.045, Subdivision 3a without first exhausting the HEALTH PLAN Complaint procedure or 30 days after the HEALTH PLAN's final determination of the formal Complaint,
3) request a second opinion as required under Section 8.7., and
4) request an expedited determination.

F. The circumstances under which the medical service will be continued if a hearing is requested..." Minnesota Contract, pages 79-80.

"2.4.3 Enrollment Counseling: ...
a. Educating the family.their rights to file grievances and complaints." Missouri RFP, page 34.

"19) How to register a complaint with a health plan or file a grievance including the procedures available to a member to challenge or appeal the member's coverage failure of the health plan to cover a service, or relationship to the organization." Missouri RFP, page 44.

"The health plan must make the grievance procedures available orally and in writing in the member's primary language. The State Medicaid agency and the health plan shall inform members and applicants about both the health plan's internal grievance procedures and the State's grievance procedures at the time of initial enrollment, each time a service is denied, reduced or terminated, or any other time of member or applicant dissatisfaction with the health plan. Summary information regarding nature of grievances and resolution may be publicly disclosed by the State in a consumer information book." Missouri RFP, page 71.

"SECTION 20 ENROLLEE COMPLAINTS, GRIEVANCES AND APPEALS...
The CONTRACTOR shall inform applicants and ENROLLEES of services provided through this Contract and the ENROLLEES right to present grievances to the CONTRACTOR, the DEPARTMENT, the Insurance Commissioner and/or Office of Civil Rights...

A. Complaints: ...
The CONTRACTOR must establish: ...

2. a mechanism to inform ENROLLEES about the informal process which ENROLLEES can use to make verbal complaints, to ask questions, and to get problems resolved without going through the formal, written grievance process;

3. a mechanism to inform ENROLLEES of the formal grievance process if the CONTRACTOR is unable to resolve the complaint within five (5) working days and that the ENROLLEE has fifteen (15) days to file a written grievance with the CONTRACTOR if a complaint is unresolved or adverse." Montana Contract, page 15.

"2.8 ENROLLEE HANDBOOK
Mail a Medicaid-specific ENROLLEE handbook to a new ENROLLEE'S household within seven working days of initial enrollment notification to the CONTRACTOR, which at a minimum, shall include: ...
(12) informal complaint and formal grievance procedures and policies on the processes for requesting filing of a grievance, DEPARTMENT review and fair hearing." Montana Contract, page 51.

"STANDARD ENROLLEE HANDBOOK LANGUAGE
The following standard language must be included in MEDICAID ENROLLEES' member handbooks unless alternate language is approved by the DEPARTMENT in writing...

Complaints and Grievances
[Insert CONTRACTOR's internal complaint and grievance policies here.]

If you are not satisfied with [CONTRACTOR's name] decision about your complaint, you may appeal the decision. Write your complaint and mail it to the address below. You must do this within 45 DAYS of receiving a letter about [CONTRACTOR's name] decision...

If you believe you have been discriminated against because of your disability you can choose to file your complaint with the following before going through any other complaint process:

Office of Civil Rights
U.S. Department of health and Human Services." Montana Contract, page 58.

"11.3 Enrollment Activities: The EBS shall complete the following enrollment activities for mandatory clients (and also for potential mandatory clients, if requested), in coordination with the plan and the Department:
(a) Educate clients concerning the full range of Medicaid benefits, including all NHC options and covered services,
including...
(14) An explanation of the complaint/grievance/appeal/process." Nebraska Contract, pages 61-62.

"11.3.2 Client-Requested Materials: The EBS shall also coordinate the following with the plan if the following, or similar, information is requested by the mandatory client or potential mandatory client: ...
(c) Complaint, grievance and appeal procedures." Nebraska Contract, page 63.

"11.15.1 Advocacy Functions: Handling of client and provider complaints is a primary function of the EBS and
requires a client advocacy approach to the resolution. The EBS is responsible for the components of client advocacy, including but not limited to: ...
(b) When complaints cannot be resolved through the EBS, the EBS shall advise the client of his/her rights and responsibilities to pursue complaints, and grievances, including requesting a fair hearing. The EBS shall also inform the client of the availability of the State Ombudsman Office." Nebraska Contract, page 68.

"17.2 Rights and Responsibilities for Clients Enrolled in the Basic Benefits Package:
The following rights and responsibilities apply to clients participating in the NHC. Each plan shall inform the client, in writing and orally, about his/her rights and responsibilities.
17.2.1 Client Rights: The client has the right to: ...
(f) Make a complaint about the PCP or plan, and receive a timely response...
(h) Request a fair hearing according to 465 NAC." Nebraska Contract, page 139.

"17.4 Grievance/Appeal Process: The plan shall inform the client, in writing and verbally, of the grievance/appeal process for challenging the denial or payment of medical services." Nebraska Contract, page 141.

NEBH

"15.2 Rights and Responsibilities for Clients Enrolled in the Mental Health/Substance Abuse (MH/SA) Package: The following rights and responsibilities apply to clients participating in the NHC. The PHP shall inform the client, in writing and orally, about his/her rights and responsibilities, including the right to a fair hearing under 465 NAC in the event of a denial, termination or reduction of services, or other action adverse to the interests of the client.

15.2.1 Client Rights: The client has the right to:
(f) Make a complaint about the MH/SA provider or the PHP, and receive a timely response...
(h) Request a fair hearing according to 465 NAC." Nebraska Behavioral Health Contract, page 103.

"15.4 Grievance/Appeal Process: The PHP shall inform the client, in writing and verbally, of the grievance/appeal process for challenging the denial or payment of medical services." Nebraska Behavioral Health Contract, pages 104-105.

"IV. Participant Services
A. New Participant Orientation. The Contractor must have written policies and procedures for orienting new participants about the following: ...
5. Process for filing a complaint or grievance with the Contractor, and the process for State hearing with DHCFP; process for disenrollment for cause." Nevada Contract, page 32.

"II. Enrollment
A. Enrollment Sessions. DHCFP will conduct enrollment orientation sessions prior to enrollment of participants in the Contract. Recipients will be scheduled to attend an orientation session where they are requested to select a Contractor. The content of the enrollment sessions includes information as follows: ...
4. Grievance and appeal rights provided by the HMO and the DHCFP hearing process, and the procedures for using them." Nevada Contract, page 46.

"D. COMMUNICATION OF POLICIES TO PARTICIPANTS
Upon enrollment, participants are provided a written statement that includes information on the following: ...
9. Procedures for resolving complaints and/or grievances and for recommending changes in policies and services..." Nevada Contract, page 66.

"Article II
Functions and Duties of Contractor
In consideration of the Agreement of the State contained in Article III, Contractor agrees: ...

2.10 GENERAL INFORMATION-----To provide to Medicaid Enrollees in the Enrollment Area, from time to time, general information about services offered by Contractor...and grievance review procedures...

2.23 MEMBER SERVICES-----The Contractor shall ensure to Enrollees the following:
A. The provision of all necessary information required to utilize HMO Covered Services and other benefits ppropriately...
(2) Enrollee Orientation and Educational Materials: The Contractor shall provide an orientation. by telephone, mail or in person, to Enrollees regarding the Plan's delivery system within thirty (30) days of the initial date of enrollment...At a minimum, the curriculum and materials for orientation and ongoing educational efforts shall include, but not be limited to: ...
f. the process by which to file a grievance with the Contractor...

C. A process to submit and resolve Enrollee complaints and grievances to the Contractor.

(1) Complaint and Grievance Procedures Process and Reporting: .The Contractor shall: ...
c. communicate the availability of member services and a grievance procedure to all Enrollees at the time of enrollment in a manner which clearly informs Enrollees about their right to file a complaint or grievance, including the steps Enrollees must follow..." New Hampshire General Service Agreement, pages 9, 13-15.

"ARTICLE 11
MARKETING...
11.2 The contractor will prepare...marketing materials for distribution to enrollees or, where applicable, an authorized person, and will include basic information about its plan. All marketing materials and presentations must, at a minimum: …
I. Explain the Grievance Procedure…" New Jersey Contract, pages 63-64.

"ARTICLE 12
ENROLLEE NOTIFICATION
12.1 Prior to the effective date of enrollment, the contractor shall provide each enrolled case or, where applicable, an authorized person, with a… member handbook, the content and format of which shall have... including but not limited to: ...
N. Procedures for resolving complaints, as approved by the DMAHS, and a description of the contractor's grievance procedure, including the name, title or department; address; and telephone number of the person(s) responsible for assisting enrollees in grievance resolutions…" New Jersey Contract, pages 68-70.

"ARTICLE 13
GRIEVANCE PROCEDURE...
13.2 The contractor shall provide all enrollees or, where applicable, an authorized person upon enrollment in the plan pursuant to this contract, with a concise statement of the contractor's grievance procedure and the enrollees' rights to pursue the fair hearing process described in N.J.A.C. 10:49-10.1 et seq. if the enrollees or, where applicable, an authorized person are dissatisfied with the outcome of the grievance process. The information may be provided through an annual mailing, a member handbook, or any other method approved by DMAHS…" New Jersey Contract, page 72.

"Standards for Internal Quality Assurance Programs of HMOs, HIOs, and PHPs Contracting with Medicaid...
STANDARD X: ENROLLEE RIGHTS AND RESPONSIBILITIES - The organization demonstrates a commitment to treating members in a manner that acknowledges their rights and responsibilities...
D. Communication of policies to enrollees/members - Upon enrollment, members are provided a written statement that includes information on the following: ...
7. Procedures for appealing decisions adversely affecting the member's coverage, benefits, or relationship to the organization...
10. Procedures for voicing complaints and/or grievances and for recommending changes in policies and services…" New Jersey Contract, pages 203-215.

"2.A.1.e.iii The CONTRACTOR shall provide each member and/or legal guardian with written policies and procedures concerning: ...
(E) the procedure for appealing a decision that adversely affects the member's coverage, benefits, or other relationship with the MCO..." New Mexico Contract, page 5.

"2.A.1.g Members' Bill of rights
The CONTRACTOR shall have a written policy which is approved by HSD and complies with any applicable ADA requirements to ensure that members are treated in a manner that respects their rights. ...The CONTRACTOR shall distribute the policy on members' rights and responsibilities to members and/or legal guardians and participating practitioners. The CONTRACTOR's staff, staff of any subcontractor, and network providers shall honor the policies.
The policy shall address the following at a minimum: ...
2.A.1.g.iv Members and/or legal, guardians have a right and the means to voice complaints or file grievances about the care provided by the MCO..." New Mexico Contract, pages 6-7.

"2.A.2.c Benefit Denials
The CONTRACTOR shall clearly document and communicate the reasons for each benefit denial...
2.A.2.c.ii There shall be established an accessible grievance mechanisms that comply with Section 2.E. herein for both providers and members; the notification of a denial will include a description of how to file a grievance and notice that. for members only, after the MCO internal grievance procedures are exhausted, an administrative hearing is available from HSD. The notice will contain the procedure for obtaining an administrative hearing." New Mexico Contract, page 9.

"2.A.6.e Member Handbook
The CONTRACTOR is responsible for providing members with a member handbook...
The handbook must include: ...
2.A.6. e.vi Notice to members on the grievance process..." New Mexico Contract, pages 20-21.

"2.E.3 Information Distribution
The CONTRACTOR shall have the following responsibilities with regard to the distribution of information:

2.E.3.a Member Notice With Initial Enrollment
Upon enrollment, the CONTRACTOR shall provide members, at no cost, with a member information sheet or handbook which provides information on how they and/or their representative(s) can file a grievance and about the grievance resolution process. The member information shall also advise members of their right to file a request for an administrative hearing with HSD Hearings bureau, without first utilizing the MCO grievance process, in those instances in which Medicaid benefits are terminated, suspended, reduced or not-provided. The information shall meet the standards for communication specified in Section MAD -606.A.7, QUALITY MANAGEMENT, Standards for Member communication. The CONTRACTOR may not establish time limits of less than one year from the date of occurrence for the member to file a formal grievance.
2.E.3.a.i Method of Obtaining Hearing and the Right to Representation. The information shall include the method by which a hearing may be obtained and the right to self- representation or the use of a spokesperson or legal counsel.
2.E.3.a.ii Non-Disclosure of Information. The member information shall include a statement that information about the grievance is not disclosed without the member's permission unless disclosure is required by law.
2.E.3.a.iii Non-Retaliation. The information shall include a statement which verifies that the member shall not be subjected to retaliation for filing a grievance." New Mexico Contract, pages 55-56.

"14. COMPLAINT AND APPEAL PROCEDURE...
14.2 Notification of Complaint and Appeal Program
a) The Contractor's specific complaint and appeal program shall be described in the Contractor's member handbook and shall be made available to all Enrollees." New York Contract, page 14-1.

"25. Fair Hearings...
25.6 Contractor's Obligations...
H) The information describing fair hearing rights, aid continuing, complaint procedures and utilization review appeals shall be included in all Medicaid managed care member handbooks and shall comply with SDOH's member handbook guidelines." New York Contract, pages 1-4.

"Appendix E
New York State Department of Health
Member Handbook Guidelines...

HANDBOOK REQUIREMENTS...
n) Grievance Procedures (complaints)
i) Right to file a grievance regarding any dispute between the Contractor and an Enrollee.
ii) Right to file a grievance orally when the dispute is about referrals or covered benefits.
iii) Explanation of who in the plan to call, along with the Contractor's toll-free number.
iv) Time frames and circumstances for expedited and standard grievances.
v) Right to appeal a grievance determination and the procedures for filing such an appeal.
vi) Time frames and circumstances for expedited and standard appeals.
vii) Right to designate a representative...

o) Fair Hearing

Explain that:

i) Enrollee has a right to a State Fair Hearing and Aid to Continuing in some situations.
ii) Describe situations when the Enrollee may ask for a fair hearing...
iii) Describe how to request a fair hearing (assistance through member services, LDSS, State fair hearing contact).

p) External Appeals
i) Description of circumstances where a person may request an external appeal
ii) Time frames for applying for appeal and for decision-making
iii) How and where to apply
iv) Describe expedited appeal time frame
v) Process for Contractor and Enrollee to agree on waiving the UR appeal process." New York Contract, Appendix E,
pages E-1-E-6.

"APPENDIX F
New York State Department of Health
Medicaid Managed Care Complaint and Appeals Requirements...

III. Complaint Procedures
a) The MCO shall describe its complaint and appeal procedure in the member handbook...
b) Anytime the MCO denies access to a referral; denies or reduces benefits or services; or determines that a requested benefit is not covered in the MCO's benefit package, the MCO shall provide written notice of the procedures for the Enrollee to file a complaint, including the notice containing information on the right to request a fair hearing." New York Contract, Appendix F, pages F-1-F-2.

"APPENDIX J
GUIDELINES FOR MEDICAID MCO COMPLIANCE
WITH THE AMERICANS WITH DISABILITIES ACT (ADA)...
IV. PROGRAM ACCESSIBILITY
B4. Complaints and Appeals
Standard for Compliance
The MCO will establish and maintain a procedure to protect the rights and interests of both enrollees and managed care plans by receiving, processing, and resolving grievances and complaints in an expeditious manner, with the goal of ensuring resolution of complaints and access to appropriate services as rapidly as possible.

All enrollees must be informed about the complaint process within their plan and the procedure for filing complaints. This information will be made available through the member handbook, the SDOH toll-free complaint line [1-(800) 206-8125] and the plan's complaint process annually, as well as when the MCO denies a benefit or referral." New York Contract, Appendix J, pages J-2-J-9.

"GRIEVANCE PROCEDURES
The Plan shall have a timely and organized internal grievance system with written policies and procedures (42 CFR 434.32)...
B. The Plan shall develop written policies and procedures which detail the operation of the internal grievance process and which shall:
1. be approved by the Plan's governing body and be the direct responsibility of the governing body;
2. be approved by the Division prior to implementation;
3. be distributed to all Members upon enrollment, and to all subcontractors at time of subcontract;
4. inform Members and applicants about the internal Plan grievance process and state appeals process set forth in
10 NCAC 26I orally and in writing, through a State developed or approved description of the grievance process, at:
1) the time of enrollment;
2) each time a service is denied, reduced, and /or terminated, and/or whenever a Plan or provider does not take a course of action or treatment normally taken for the Member's medical problem;
3) and when a patient is billed for service because the Plan has denied payment for a covered Medicaid service provided by an out-of-network provider.
5. name specific individuals in the Plan who have authority to administer the internal grievance policy...

C. When a Plan denies, reduces or terminates a Member's request for service or requests the Division to disenroll a Member, a written notice to the Member (or the Member's authorized representative) must explain:
1. that Member has the right to a second opinion if medically necessary, at the Plan's expense and how to exercise that right;
2. how to contact the consumer relations or member services office and how to file an internal grievance with the Plan;
3. the right to file an informal or formal appeal with the State pursuant to 10 NCAC 26I and how to obtain more information about those procedures;
4. that filing or resolving a grievance through the Plan's internal grievance mechanism is not a prerequisite to filing an informal or formal appeal with the State pursuant to 10 NCAC 26I;
5. the circumstances that will cause an expedited hearing;
7. the right to be advised or represented by a lay advocate or attorney and of the potential availability of free legal services;
8. the right to enroll in another Plan if the Member is not satisfied at the end of the internal grievance or State appeal process;
9. that the Health Benefits Advisor is available to the Member/Applicant at any time, to provide assistance during the internal plan grievance process or the State appeals process under 10 NCAC 26I...

E. The Plan must make the information and notices described in this appendix readily available orally and in writing in the recipient's primary language.
F. Information regarding the nature of internal grievances and resolution may be publicly disclosed by the State in consumer information materials." North Carolina Contract, Appendix IX, pages 1-3.

"B. The Contractor shall inform applicants and recipients of services provided through this contract of any right there may be to present grievances to the Contractor and the Department, upon enrollment, and annually thereafter.
C. As required by 42 CFR 434.32, the Department must approve the Contractor's grievance procedure in writing. Unless a grievance procedure is approved by the Department in writing, the Contractor shall implement the following grievance procedure: ...
(5) A mechanism to inform enrollees about the existence of the formal and informal grievance processes." North Dakota Contract, page 14.

"2.15 Enrollee handbook and Membership Card
Upon request, the Contractor shall provide a Medicaid specific enrollee handbook, to potential enrollees and to the recipient household within one week of initial enrollment notification to the Contractor, which at a minimum, shall include: .
(5) Informal and formal grievance procedures...
(13)Policies on the processes for requesting filing of a grievance, Department review and fair hearing." North Dakota Contract, Attachment C, pages 16-17.

"ATTACHMENT E: STANDARD ENROLLEE HANDBOOK LANGUAGE
The following standard language must be included in Medicaid enrollees' member handbooks unless alternate language is approved by the Department. This language is not intended to be comprehensive: .
Complaints
[Insert Contractor's internal complaint, grievance, and appeal policies here.]
If you are not satisfied with [Contractor's name] written decision about your appeal, you may appeal the decision. Write your complaint and mail it to the address below. You must do this within fifteen days of receiving a letter about [Contractor's name] decision.
Appeals Supervisor
Department of Human Services
600 East Boulevard Avenue
Bismarck, ND 58505-0250." North Dakota Contract, Attachment E, page 1.

"5101:3-26-03 Managed care plan: Covered services...
(H) The MCP must notify an enrollee of the right to request a state hearing if the MCP learns that the enrollee has been billed by a provider due to the MCP's denial of payment and that notice has not been issued. Such notification must be in accordance with rule 5101:6-2-35 of the Administrative Code, including the use of the procedures and forms specified." Ohio RFP, Appendix E, OAC 5101:3-26-03, pages 1-2.

"Member Handbooks
The following bullets outline the required elements of each Health Plan member handbook...
Member handbooks must contain the following information (sections referenced can be found in the Health Plans Contract)...
* How to register a complaint or file an appeal (Health Plan and OHCA)." Oklahoma RFP, pages 164-165.

ORMH

"4. Client Notices...
Contractor shall make available in all clinics frequented by OMAP Members information provided by Division concerning client notices, complaints and hearings." Oregon Mental Health Contract, page 10.

"F. Information Materials and Education of OMAP Members...
Contractor shall offer member orientation that includes information on the contractor's Grievance and Complaint process.

G. OMAP Member Rights...
2. Contract shall assure that OMAP Members receive information on the rights specified in OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Members Rights and Responsibilities. Contract shall give particular attention to the following rights: .
k. The right to make a Complaint or request a hearing as described in Exhibit G, Oregon Health Plan Mental Health Services Complaint and Hearings Process;
l. The right to request an Expedited Hearing if the OMAP Member feels the mental health problem is urgent or emergent and cannot wait for the normal hearing process...
n. The right to receive, within 30 calendar days of Enrollment, written materials describing at least the following topics: .how to make a Complaint." Oregon Mental Health Contract, pages 27-29.

"Oregon Health Plan Mental Health Services Client Notices, Complaint and Hearing Process...
2. Hearing Process
Contractor shall have the following responsibilities in resolving disagreements with OMAP Members and/or OMAP Member Representatives: ...
D. Have a method of informing OMAP members about compliant and MHDDSD Hearings procedures. Information provided to OMAP Members shall include the following:
(1) written material, or alternative forms as required by the OMAP Member's special need, describing these processes;
(2) Assurance that clinical information related to the Complaint or MHDDSD Hearing issue will be kept confidential except to the extent that sharing of such information between Contractor and Division, and other persons authorized by the OMAP Member, is necessary to resolve the issue;
(3) Availability of Complaint forms, Notice of Hearing Rights (MHDDSD-OHP-0505-3/98), Notice of Complaint Process (MHDDSD-OHP-0504-3/98), and Administrative Hearing Request Forms (AFS 443) in all offices; and
(4) Assurance that Contractor and its Participating Providers will take no retaliatory action against the OMAP Member for making a Complaint or requesting a MHDDSD Hearing." Oregon Mental Health System, pages G1-G3.

"D. Member Enrollment and Disenrollment...
8. New Member Orientation
The HMO must have written policies and procedures, specific to that particular HMO, for orienting new members to... how to register a complaint, file a grievance, or request a fair hearing.." Pennsylvania RFP, pages 20-27.

"12. Member Handbook...
a. Required Information...
At a minimum, the member handbook shall include: ...
Information regarding the grievance and appeals process including how to register a complaint with the HMO, with the department, and how to file a formal grievance, the right to continue to receive current services pending appeal, the right to appeal in the case that the HMO denies a service on the basis that it was deemed not medically necessary, and to interim relief, and the relevant time frames of the process." Pennsylvania RFP, pages 29-30.

"MEMBER SERVICES...
3. Education and Outreach.
Topics of educational information, to be developed and distributed should include : .
how to resolve problems with the HMO (including the grievance and appeals process)." Pennsylvania RFP, pages 35-36.

"N. GRIEVANCES AND APPEALS...
The HMO must provide enrollees with a clearly written, straight forward document, outlining their rights as members of the HealthChoices Program, including their right to file a complaint or grievance, as well as, their right to request a Departmental fair hearing. This information must include a toll-free phone number for members to facilitate the communication of a complaint or grievance." Pennsylvania RFP, pages 80-81.

PABH

"c. Member Services (Part IV, Section D.3)...
3) Describe member orientation, tailored to the needs of populations served, related to: .use of the grievance and appeals process.

h. Utilization Management and Quality Assurance (Part IV, Section E.6)...
2) Describe the process to inform providers and members of appeal rights, and indicate how that process will be monitored." Pennsylvania Behavioral Health RFP, pages 22-23, 25.

"3) The MCO must publish and distribute a member handbook to all members and make it available to other interested parties upon request. The handbook must be printed at no higher than a fourth grade reading level, delineating a member's rights and responsibilities, as well as covering...
c) how to use the complaint, grievance and appeals process...

4. Complaint, Grievance and Appeal...
b. Member Complaint, Grievance and Appeal System
The MCO must develop, implement, and maintain a complaint and grievance system which provides for informal settlement of member complaints and grievances at the lowest administrative level and a formal process for appeal. The complaint and grievance system is expected to conform to the conditions set forth in Appendix H.

1) The MCO must provide enrollees/members and parents/custodians of children and adolescents (for children in substitute care, both parent, if whereabouts are known and county C&Y agency must receive information) with straight forward document that plainly and clearly outlines rights and responsibilities as members, including the right to file a complaint, grievance, or appeal. This information must include a toll-free telephone number for members to facilitate the communication of a complaint or grievance." Pennsylvania Behavioral Health RFP, pages 55-56.

"2.05.10 New Member Orientation
Contractor shall have written policies and procedures for orienting new members to their benefits the role of the PCP, what to do in an emergency or urgent medical situation, how to utilize services in other circumstances, how to register a complaint or file a grievance and advanced directives. These policies and procedures shall take into account the multi-lingual, multi-cultural nature of the population." Rhode Island RFP, page 15.

"2.05.14.01 Required Information
The member handbook must be written at no higher than a sixth-grade level and contain at least the following: ...
- Information on Member Services, and how to register a complaint with the Health Plan or file a formal grievance, including filing grievances with the Department of Human Services." Rhode Island RFP, page 17.

"8.4 Member's Rights and Responsibilities
The Contractor shall furnish Medicaid HMO Program members with both verbal and written information about the nature and extent of their rights and responsibilities as a member of the Contractor's plan...The minimum information shall include: ...the right to file grievance or complaints about the Contractor and/or care provided.

9 COMPLAINT AND GRIEVANCE PROCEDURES...
9.3 Notice
The Contractor shall ensure that all Medicaid HMO Program members are informed of the Contractor's complaint and grievance procedures. The Contractor shall provide to each member a member handbook that shall include escriptions of the Contractor's complaint and grievance procedures. Forms on which members may file complaints, grievances, concerns or recommendations to the Contractor shall be available through the Contractor, and must be provided upon request of the member. Notice of resolution of grievances shall include notification to the members of their right to appeal the decision to the SCDHHS, Division of Appeals and Hearings for further review if the member continues to be dissatisfied with the outcome of the grievance. The Contractor shall provide to its Medicaid HMO members notice of grievance rights each time a covered service is denied, reduced and/or terminated." South Carolina Contract, page 46.

"Quality Assurance and Utilization Review Requirements
All HMOs that contract with the SCDHHS to provide Medicaid HMO Program Services must have a Quality Assurance (QA) and Utilization Review (UR) process that meets the following standards: .

10. The HMO SHALL FURNISH Medicaid members with approved written information about the nature and extent of their rights and responsibilities as a member of the HMO. The minimum information shall include: ...
(e) The right to file grievance or complaints about the HMO and/or care provided." South Carolina Contract, Appendix G, pages 1, 6.

"MARKETING AND EDUCATIONAL MATERIALS AND ACTIVITIES...
SDHHS has established the following minimum requirements for the Contractor's Medicaid managed care marketing/educational materials: .
* The Contractor's written materials must provide the following information on the responsibilities and rights of a Medicaid HMO program...
* An explanation of member's complaint(s) and grievance(s), appeals rights, and advanced directive rights;" South Carolina Contract, Appendix J, page 8.

"2-6. Enrollment...
b. Enrollment Procedures
1. The CONTRACTOR shall give a full written explanation of the MCO's plan to enrollees after their enrollment in the plan. This written explanation shall, at a minimum, include:
(f) Appeal procedures;
(g) Notice to the enrollee that in addition to the enrollee's right to file an appeal for actions taken by the CONTRACTOR, the enrollee shall have the right to request reassessment of eligibility related decisions directly to TennCare." Tennessee Contract, pages 34-39.

"2-9. Complaint and Appeal System Requirements
The CONTRACTOR shall provide readable materials reviewed and approved by TENNCARE, informing enrollees of their complaint and appeal rights." Tennessee Contract, page 43.

"Guidelines for Internal Quality Monitoring Programs of Managed Care Organization Contracting with TennCare...

STANDARD IX: ENROLLEE RIGHTS AND RESPONSIBILITIES -
The organization demonstrates a commitment to treating members in a manner that acknowledges their rights and responsibilities.

D. Communication of Policies to Enrollees/Members - Upon enrollment, members are provided a written statement that includes information on the following:
7. procedures for appealing decisions adversely affecting the member's coverage, benefits, or relationship to the organization...
10. procedures for voicing complaints and/or grievances and for recommending changes in policies and services." Tennessee Contract, pages QMC-2-10.

"8.6 MEMBER COMPLAINT PROCESS...
8.6.5 HMO's complaint procedures must be provided to Members in writing and in alternative communication formats. A written description of HMO's complaint procedures must be in appropriate languages and easy for Members to understand. HMO must include a written description in the Member Handbook. HMO must maintain at least one local and one toll-free telephone number for making complaints." Texas Contract, pages 81-82.

"B. Member Orientation
1. Initial Contact - General Orientation...
During the initial contact the CONTRACTOR Representative must provide, at a minimum, the following information to the Enrollees or potential Enrollees: ...
c. the client's rights and responsibilities as an Enrollee of the Health Plan, including the right to file a grievance and how to file a grievance..." Utah Contract, Attachment B, pages 5-6.

"3. Member Handbook...
At a minimum, the member handbook must explain in clear terms the following information: ...
i. How to register a complaint or grievance... " Utah Contract, Attachment B, page 8.

"b. Annual Education on .Grievance Procedures...
The CONTRACTOR must annually reinforce, in writing, to Enrollees how to... register a complaint or grievance." Utah Contract, Attachment B, page 9.

"C. General Information to be Provided to Enrollees
The CONTRACTOR will make the following information available to Enrollees and potential enrollees on request:...
3. The procedures available to Enrollees and providers to challenge or appeal the failure of the CONTRACTOR to cover a services." Utah Contract, Attachment B, page 28.

UTMH

"5. Medicaid Enrollee Information...
b. Before implementation of the contract, the CONTRACTOR will produce an informational brochure. At a minimum the brochure must explain in clear terms the benefits available to Enrollees, including.complaints and grievance procedures." Utah Mental Health Contract, page 10.

"6. Grievance Information - In accordance with 42 DFR 431, Subpart E, the CONTRACTOR must inform Enrollees both orally and in writing of their right to file a grievance at the time services are denied, discontinued, suspended, or reduced. This information must be provided in simple, clear language and include the information needed for the Enrollee to file a grievance. The CONTRACTOR shall inform the Enrollee what to expect once the grievance process begins, and that the final decision of the CONTRACTOR may be appealed to DHCF. DHCF will ensure that Medicaid clients are informed of their rights, including the grievance procedures." Utah Mental Health Contract, page 11.

"Article V
COMPLAINTS AND GRIEVANCES...
D. When a Medicaid Enrollee or provider files a complaint with the CONTRACTOR, the CONTRACTOR must provide the Enrollee or provider with a written copy of the grievance procedures as described in Article IV, Subsection A.4." Utah Mental Health Contract, page 17.

"17. Enrollee Information Packet
The Enrollee Information Packet must include at a minimum the following sections.
k. Complaints, Grievances, and Appeals
i. A description of the informal and formal grievance procedures, including but not limited to the issues that may be resolved through the informal or formal grievance or appeals processes, the fact that enrollees have the right to appeal directly to the Department, the process for obtaining necessary forms, and procedures to register a grievance with the Contractor.
ii. The telephone numbers to register complaints regarding providers (Health Professionals, 1-800-533-1560) and HMOs (Bureau of Insurance, 1-800-552-7945)." Virginia Contract, pages 30-33.

"E. MEMBER INFORMATION [RR 5].
3. The contractor must provide written information about: [RR 5.3]
a) how to voice a complaint; [RR 5.3.1]
b) how to appeal a decision that adversely affects the member's coverage, benefits, or relationship to the organization; and [RR 5.3.2]

4. Additional Requirements for Healthy Options, BHP Plus, and BHP/S Medical Members
The contractor's written information to HO, BHP-Plus, and BHP/S clients must include: ...
b) that, when requested, plans must assist members in using the complaint and appeal process, and they must assure members that information will be kept confidential except as needed to process the complaint or appeal. (B)
c) HO, BHP Plus, and BHP/S-Medical members also receive information about their right to file a Department Fair Hearing request, how to do so pursuant to chapter 388-08 WAC, and their right to a second opinion if services or a referral for services have been denied.
d) the member's right to initiate a complaint or file an appeal at any time.
e) The contractor must assure that written information provided to members is comprehensible to its intended audience, well designed, and at the sixth grade reading level. The contractor must distribute member information that is readable, easily understood, and consumer tested." Washington Contract, QIP-2000 Standards, pages 26, 27-29.

"3.3 Grievance Procedures...
Managed Care Plan Requirements...
(2) A detailed description of the Managed Care Plan's subscriber grievance procedure shall be included in all group and individual contracts as well as any certificate or member handbook provided to subscribers. This procedure shall be administered at no cost to the subscriber." West Virginia Contract, page 8.

"3.15 Enrollee Handbook and Member Information
The Managed Care Plan shall mail an enrollee handbook to the enrollee's household within one week of official enrollment notification to the Managed Care Plan. The enrollee handbook at a minimum, shall include:
* informal and formal grievance procedures...
In addition, the Managed Care Plan must make the following information available to enrollees and potential enrollees on request: ...

* the procedures available to enrollees and providers to challenge or appeal the failure of the Managed Care Plan to cover a services." West Virginia Contract, pages 16-17.

"II-4
ENROLLEE INFORMATION...
The MCO must provide enrollees with a written statement, at the time of enrollment and at least annually thereafter, with information on: ...
* Procedures for resolving enrollee issues, including complaints or grievances and issues relating to authorization of, coverage of, or payment for services.

The MCO must also provide written notice to any enrollee who requests it regarding: ...
* The number of grievances and appeals and their disposition in the aggregate, in a manner and form specified by the Bureau for Medical Services and/or the Department of Insurance." West Virginia Contract, Exhibit F, page 9.

"D. Communication of policies to members - Upon enrollment, members are provided a written statement that includes information on the following: ...
10. Procedures for voicing complaints and/or grievances and for recommending changes in policies and services." West Virginia RFA, Appendix E, pages E10-E11.

"Grievance Procedures
The MCP's grievance procedures must comply with West Virginia Statutes 33-25A-12 which state: ...
(2) A detailed description of the MCP's subscriber grievance procedure shall be included in all group and individual contracts as well as any certificate or member handbook provided to subscribers. This procedure shall be administered at no cost to the subscriber. An HMO subscriber grievance procedure shall include the following:
(a) Both informal and formal steps shall be available to resolve the grievance. A grievance is not considered formal until a written grievance is executed by the subscriber or completed on such forms as prescribed and received by the HMO;
(b) Each HMO shall designate at least one grievance coordinator who is responsible for the implementation of the HMO's grievance procedure;
(c) Phone numbers shall be specified by the HMO for the subscriber to call to present an informal grievance or to contact the grievance coordinator. Each phone number shall be toll free within the subscriber's geographic area and provide reasonable access to the HMO without undue delays. There must be an adequate number of phone lines to handle incoming grievances;
(d) An address shall be included for written grievances;
(e) Each level of the grievance procedure shall have some person with problem solving authority to participate in each step of the grievance procedure." West Virginia RFA, Appendix F, page F1.

4.4.2.2 Member Handbook Minimum Contents
The member handbook must include standards for enrollee rights as specified in Standard X of Appendix E. The handbook must include the following: ...
h) A description of the MCP's grievance and appeals procedures...
t) Telephone numbers for the HBM and for filing a State grievance...

4.5 Education
4.5.1 New Member Orientation
The MCP must have written policies and procedures for orienting new Medicaid enrollees about the following: ...
e) How to register a complaint or file a grievance." West Virginia RFA, pages 32-34.

"T. ENROLLE HANDBOOK and EDUCATION and OUTREACH FOR NEWLY ENROLLED RECIPIENTS - Within one week of initial enrollment notification to the HMO, mail to caseheads an enrollee handbook which is at the 'sixth grade level of comprehension level' and which at a minimum will include information about: ...
5. Informal and formal grievance procedures, including notification of the enrollee's right to a fair hearing,
6. Grievance appeal procedures." Wisconsin Contract, pages 18-19.

"VIII. GRIEVANCE PROCEDURES
Medicaid enrollees may grieve regarding any aspect of service delivery provided or arranged by the HMO.
A. PROCEDURES - The HMO shall: ...
5. Inform enrollees about existence of the formal and informal grievance processes and how to use the formal and informal grievance process." Wisconsin Contract, page 57.

"D. NOTIFICATIONS OF DENIAL OF NEW BENEFITS TO RECIPIENTS - When an HMO, its gatekeeper, or IPA denies a new service the HMO shall notify the affected recipient(s) in writing of:
1. The nature of the intended action.
2. The reasons for the intended action.
3. The specific regulations supporting the action.
4. The fact that the enrollee may file a grievance with either the HMO or Department and the address of the HMO and the Department.
5. The fact that the enrollee can receive help in filing a grievance by calling the Enrollment specialist or the Ombudsman." Wisconsin Contract, page 60.