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Problem Resolution Process

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Published on . Last modified on March 9, 2015

Monterey County Behavioral Health is committed to solutions to the problems and concerns you may encounter during the course of receiving services with us. Clients will not be subjected to discrimination, intimidation or any other retaliation for expressing concerns, filing a Grievance or Appeal. If you are unhappy with any issue related to the mental health services you are receiving, you have options that may help you with the resolution of these issues. Here are some options for you to consider when deciding the next steps to take. (Para una copia de el Proceso de Resolucion de Problemas, oprima aqui)

Change of Clinician

The “yellow” form is located in all outpatient clinic lobbies. The form is used to request a change in psychiatrist, psychologist, social worker, or case manager.

How do I ask for a change of clinician?

You complete the yellow Change of Clinician form and place it in the secure box also located in the lobby.

What happens after I complete this form?

The form will be reviewed by the Program Manager. You may receive a telephone call from a program manager requesting further information and/ or to begin the process of identifying solutions. The solutions may vary from person-to-person as each situation is unique.


Notice of Adverse Benefit Determination (NOABD)

What is a Notice of Adverse Benefit Determination (NOABD)?

A Notice of Adverse Benefit Determination is often referred to as a NOABD. This is a form you receive from Monterey County Behavioral Health that gives you information about a decision or “action” that was made about why you are not eligible to receive or to continue to receive Medi-Cal specialty mental health and/or substance use disorder services. The form will give you specific information on:

  • The specific reason the decision was made.
  • Information about what your rights are if you do not agree with the decision.
  • Information about the Grievance, Appeal, or Expedited Appeal process.
  • Information on the State Fair Hearing process.
  • Information on the deadlines to request a grievance, appeal, expedited appeal, or State Fair Hearing process.

What are “actions” by the Behavioral Health Plan?

  • Denies or limits authorization of requested services, including the type and level of service
  • Reduces, suspends or terminates a previously authorized service
  • Denies in whole or in part, payment for the service
  • Fails to provide services in a timely manner
  • Fails to act within the time frames for the disposition of grievance and/or the resolution of expedited appeals

What should I do if I get a Notice of Adverse Benefit Determination (NOABD)? 

  1. Read all the information on the form.
  2. Pay close attention to the information regarding the timeline you have to file a grievance, appeal, expedited appeal, and State Fair Hearing.

What should I do if I do not agree with the decision described in the Notice of Adverse Benefit Determination (NOABD)?

You may file an Appeal.


Appeals Process

An appeal is a request for a review of a problem you have with the mental health plan regarding a denial or changes in your mental health services as mentioned in the NOABD section above.

Who can file an Appeal?

Those who have Medi-Cal and disagree with the decision or action taken by the mental health plan can request an Appeal.

There are two types of Appeals.

There is a standard Appeal and an Expedited Appeal.

Standard Appeal

What is a standard Appeal?

  • You may file an Appeal in writing, on the phone, or in person.
    • If you file by phone, you MUST follow it up with a written Appeal; the date of your phone call is considered the filing date—remember this verbal request must be followed up by a request in writing.
    • If you file verbally in person, you MUST follow it up with a written Appeal. The mental health plan will send you a written confirmation that you Appeal was received and is being processed
  • The mental health plan will send you a written confirmation that you Appeal was received and is being processed
  • The mental health plan may take up to 30 calendar days to review your standard Appeal.

What is the deadline to file an Appeal?

You must file an Appeal within 60 days from the date the action or decision was taken. This usually means the date on the NOABD.

Where can I request a standard Appeal?

Behavioral Health Plan Deputy Director
1441 Constitution Blvd., Bldg. 400, Suite 202
Salinas, CA 93906
Phone (831) 796-1700

Expedited Appeal

What is an Expedited Appeal?

It is a faster way to decide an Appeal. This type of Appeal process is similar to the Standard Appeal, but an Expedited Appeal must meet certain requirements below:

  • You may request an Expedited Appeal verbally and you do not have to put your request in writing.
  • If you think that waiting up to 30 days for a standard Appeal decision will jeopardize your life, health, or ability to attain, maintain, or regain maximum function.
  • If the mental health plan agrees that your Appeal meets the requirements for an Expedited Appeal, then the mental health plan will resolve your expedited Appeal within 72-hours from the date your Expedited Appeal as received.
    • The mental health plan will notify you and all affected parties orally and in writing of the decision of the Expedited Appeal.
  • If the mental health plan decides that your Appeal does not qualify for an Expedited Appeal, then the mental health plan will notify you right away (verbally) and in writing within two (2) calendar days from the date the Appeal was received.

How do I file a standard or expedited Appeal?

You may call your mental health plan and speak with a representative at (831) 796-1700 or write to the Mental Health Deputy Director at 1441 Constitution Blvd., Bldg. 400, Suite 202, Salinas, CA 93906.

Alternatively, you may also contact the Patient’s Rights Advocate at 1 (866)908-4375 for questions regarding the Appeals process. All forms and self-addressed envelopes are available in all outpatient clinic lobbies or you may use a plain paper to write your request. This form must be signed and dated by you.


State Fair Hearing Process

What is a State Fair Hearing?

It is an independent review conducted by the California Department of Social Services to ensure you receive the specialty mental health services to which you are entitled under the Medi-Cal program.

When can I ask for a State Fair Hearing?

If you have Medi-Cal, you may ask for a State Fair Hearing whether or not you use the mental health plan’s Appeal process and whether or not you have received a Notice of Adverse Benefit Determination.  Generally, you would follow the Appeals process above, prior to requesting a State Fair Hearing.

What is the deadline to ask for a State Fair Hearing?

You have 90-days to ask for a hearing. You have 90 days from the day the mental health plan personally gave you the Notice of Adverse Benefit Determination, or the day after the postmark date of the NOABD if it was mailed, or if you filed an Appeal, 90 days after the postmark date of an Appeal.

How do I ask for a State Fair Hearing?

  1. You may fill out the form provided to you with the Notice of Adverse Benefit Determination (NOABD).
  2. Ensure you keep a copy for your records.
  3. Send the completed form to:

 Mental Health Services:                   Substance Use Services
 State Hearing Division    State Hearing Division
 California Department of Social Services    California Department of Social Services
 P.O. Box 944243    744 P Street
 Mail Station 19-37 Sacramento, CA 94244    Mail Station 9-17-37 Sacramento, CA 95814

Or

Call 1-800-952-5253. If you are deaf and use TDD, call 1-800-952-8349 


Grievance

What is a Grievance?

A grievance is an expression of unhappiness or dissatisfaction with the mental health plan.

Who can file a Grievance?

Any person who receives mental health services through the mental health plan.

What is the deadline to file a Grievance?

There is no deadline to file a Grievance, but, it is best to do it soon after the issue arises in order to provide more specific and detailed information.

How do I file a Grievance?

You may do by writing, calling, or in person at the following address:

Monterey County Behavioral Health
Quality Improvement
1611 Bunker Hill Way, Suite 120
Salinas, CA 93906
(831) 755-4545

When will I receive information back about a Grievance I filed?

You will receive written confirmation from the mental health plan that your Grievance was received. The mental health plan will make a decision about your Grievance within 90-calendar days from the date you filed your Grievance.


Forms