Appeals

Medi-Cal beneficiaries have the right to appeal when they experience what's known as an Adverse Benefit Determination. An Adverse Benefit Determination is a decision by Contra Costa Health's Behavioral Health Services Division to decline service, not see the patient, defer a requested mental health service and/ or reduce, modify or end care. This also includes Behavioral Health Services failing to provide services in a timely manner or failing to resolve a grievance or appeal within a required timeframe.

Options for Filing Appeals

• By phone: Call the Office of Quality Improvement at 925-957-5131.
• In person: Visit your Contra Costa Health Behavioral Health Services program site and say you want to file an appeal.
• Electronically: The Beneficiary Appeal and Expedited Appeal Request Form and details on how to file an appeal are on our Mental Health Provider page.

State Fair Hearings

After an appeal, Medi-Cal beneficiaries who are not satisfied with the outcome of the appeal have the right to request a State Fair Hearing. Contact the Grievance Advocate at 925-293-4942 for assistance filing. You can also call the State Fair Hearing Office at 1-800-952-5253.

Important Information You Should Know

1. You and your family will not be subject to any manner of discrimination, penalty, sanction or restriction for exercising the appeal rights.
2. If you need assistance completing this form:
   • Ask any staff at each program site. Someone will be designated to assist you.
   • Call the Grievance Advocate at 925-293-4942. Collect calls accepted. The Grievance Advocate is not a county employee.
3. You can authorize another person to act on your behalf if you sign a release of information form.
4. You or your representative may file an appeal orally or in writing. Standard oral appeals must be followed up with written, signed appeals. Call the Office of Quality Improvement at 925-957-5131 to submit an oral appeal.
5. In addition to the appeal form, you can submit written materials and present additional clinical or medical evidence in support of your position.
6. You and/or your representative may examine your medical records and any other documents considered during the appeals process before and during the appeals process.
7. Standard appeals will be reviewed by the MHP within 30 days.
8. You or your provider may request an expedited review process if the standard appeal timeframe could seriously jeopardize your life, health or ability to attain, maintain or regain maximum function. View the MediCal Beneficiary Appeals and Expedited Appeals Policy.
9. Decisions on expedited appeals will occur within 72 hours of receipt. If the MHP decides that criteria are not met for an expedited appeal, the timeline for a standard appeal will be applied, and you will be notified.
10. Appeals are reviewed by staff who were not involved in any previous level of decision-making. If the appeal is about clinical issues or is an expedited appeal, the decision-maker will have the appropriate clinical expertise and scope of practice.
11. Following the appeal decision, if an appeal is not resolved in your favor, you may file a State Fair Hearing request by calling 1-800-952-5253.

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