First Level Complaint Process
What does BH-MCO stand for?
Behavioral Health Manage Care Organization
A second level complaint must be filed within _____ days from the date the member receives written notice of the BH-MCO’s first level complaint decision
45
A member must file a _____ and receive a decision before filing a request for a Fair Hearing.
Complaint
A request for an expedited review of a complaint may be filed either in _____ or _____.
Writing or orally
The member or member’s representative may file in writing a request for an external review of the __________:.
Second Level Complaint
The provider can participate in the CRC when the member provides ______?
consent
Beacon must send the member and member’s representative an ack letter upon receipt of the complaint, which can be no later than ___ business days
5
The member or representative may request a fair hearing within _____ days from the mail date on the written notice.
120
Member’s life, physical or mental health or ability to attain, maintain, or regain maximum function would be placed in ______ by following the regular Complaint process.
Jeopardy
Writing a request for an external review must be submitted within ____ days from the date member receive the written notice of the BH-MCO’s second level complaint.
15
What is the requirement for an expedited complaint?
Health Condition
At least ______ of the second level complaint review committee may be an employee of the BH-MCO or a related subsidiary or Affiliate.
one-third
The member and the ______ will receive notification of the hearing date by letter at least 10 days before the hearing date, or a shorter time if requested by the member.
BH-MCO
The BH-MCO must mail written notice of the decision to the member, member’s representative, service provider, and prescribing provider within ________ of the decision.
2
True or False. Member is not able to continue the disputed service at the previously authorized level pending resolution of the external review.
False
There is _____ time limit for a member’s dissatisfaction with the BH-MCO or a provider.
no time limit
The BH-MCO must give the Member at least ____ days advance written notice of the second level complaint review date.
10
The Bureau of Hearings and Appeals will issue and adjudication within ___ Days of the date the member filed the first level complaint, not including the number of days before the member requested the fair hearing.
90
The BH-MCO must issue the decision resulting form the expedited review within either 48 hours of receiving the Provider’s certification or ____ hours of receiving the member’s request for an expedited review.
72
Upon the request of either the Department of Health or the Insurance Department the BH-MCO must transmit all records from the BH-MCO’s Complaint review to the requesting department within ____ days from the request in the manner prescribed by that department.
30 days
Sign in Sheets are required for ____ CRC meetings.
In person
At least ______ of the second level Complaint review committees in a year must include a consumer representative on the review committee:
20%
Fair Hearing is a hearing conducted by the Department’s ______ of ______ and Appeals or a Department designee.
Bureau of Hearing
The provider must submit a ________ as to the reason why the expedited review is needed when BH-MCO cannot determine Member’s life, physical or mental health or ability to attain, maintain, or regain maximum function
Both the ___________ and _________ will determine the appropriate agency for the review.
Department of Health and the Insurance Department