Medi-Cal beneficiaries have the right to appeal when they experienced and Adverse Benefit Determination. An Adverse Benefit Determination includes when CCBHS has made the decision to deny, reduce, modify, terminate, or defer a requested mental health service or when CCBHS fails to provide services in a timely manner or fails to resolve a grievance or appeal within required timeframes. Forms and details on how to file an appeal are available at your program site or may be initiated by calling 925-957-5160.
The Beneficiary Appeal and Expedited Appeal Request Form can be located at: cchealth.org/mentalhealth/provider/
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. They may contact the Grievance Advocate listed above for assistance in filing for a State Fair Hearing, or you may call the State Fair Hearing Office, 1-800-952-5253.
Important Information You Should Know
- If you need assistance with completing this form:
- You may ask any staff at each program site, and someone will be designated to assist you.
- You may call the Grievance Advocate (not a direct County employee) at 925-293-4942. Collect calls accepted.
- You or your representative may file an appeal orally, or in writing. Standard oral appeals must be followed-up with written, signed appeals. We (the Mental Health Plan, or MHP) will use the time that the oral appeal was filed to establish the filing date. Oral Appeals should be called in to the Office of Quality Improvement at 925-957-5160.
- The written, signed appeal should be sent as soon as possible after the oral appeal, but must be sent within 30 days or no decision will be made by the MHP regarding the action.
- You may authorize another person to act on your behalf if you sign a Release of Information form for that person to know confidential information.
- You may, in addition to this form, submit written materials and present additional clinical or medical evidence in support of your position.
- You and/or your representative may examine your medical records and any other documents or records considered during the appeal process before and during the appeal process.
- Standard appeals will be reviewed by the MHP within 30 days.
- You or your provider may request an expedited review process if you and/or your provider think that the standard appeal timeframe could seriously jeopardize your life, health or ability to attain, maintain, or regain maximum function.
- Decisions on expedited appeals will occur within 72 hours of receipt. If the MHP decides that the criteria are not met for an expedited appeal, the timeline for a standard appeal will be applied and you will be notified about this.
- Appeals are reviewed by staff that were not involved in any previous level of decision-making. If the appeal is about clinical issues, or is this should be an expedited appeal, the decision-maker will have the appropriate clinical expertise and scope of practice.
- Client/families will not be subject to any manner of discrimination, penalty, sanction or restriction for exercising their appeal rights.
- Following the appeal decision, if an appeal is not resolved in the beneficiary’s favor, Medi-Cal clients may file a State Fair Hearing request with the State by calling 1-800-952-5253.