Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

5.2.1 Introduction
The purpose of this policy is to ensure that all persons seeking or receiving services as part of the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) health system have access to a complaint process that fairly and efficiently resolves identified issues in a timely manner.

A complaint is defined as an expression of dissatisfaction with any aspect of member care, other than an action (see definition for “action”). Possible subjects for complaints include, but are not limited to: the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member’s rights.

Issues involving an action are subject to appeal, see Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons and Section 5.5 Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI). For allegations of rights violations involving persons determined to have a Serious Mental Illness (SMI) see PM 5.3 Grievance and Requests for Investigation for Persons Determined to have a Serious Mental Illness. While any member can file a complaint, the SMI grievance/request for investigation process is available only to persons determined to have a Serious Mental Illness.

All persons seeking or receiving services as part of the ADHS/DBHS system have access to the complaint process for expression of dissatisfaction with any aspect of their care. While persons seeking or receiving services are encouraged to resolve issues at the lowest possible level, they are not required to do so before utilizing the Tribal/Regional Behavioral Health Authority (T/RBHA) complaint, SMI grievance, or appeal processes.

The intent of this section is to present information for providers about the complaint process. Although the T/RBHAs are directly responsible for processing all member complaints, providers must understand how a complaint can be filed, reviewed and resolved with the goal of member satisfaction. Providers’ responsibilities include educating persons about the complaint, appeal, and SMI grievance processes and assisting with any steps in these processes and participating in resolution activities. Issues that are not resolved through the complaint resolution process may still be managed through the SMI grievance treatment and appeal processes as applicable.

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5.2.2 Terms
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php.  The following terms are referenced in this section:

Action

Appeal - Section 5.2/GA 3.1

Complaint

Grievance or Request for Investigation

Serious Mental Illness (SMI)

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5.2.3 Procedures

5.2.3-A. Complaint process

Who can file a complaint?

  • A complaint may be filed by persons enrolled in, or seeking services through the ADHS/DBHS system, a person’s family member, legal guardian, or authorized representative, and/or a service provider.
  • Complaints may be filed orally or in writing.

Where must complaints be directed?
Each T/RBHA is directly responsible for the complaint process and may not delegate the complaint function to providers.

Complaints may be filed directly with the person’s respective T/RBHA, as identified below, or initiated with the ADHS/DBHS Customer Service Unit at (602) 364-4558 or 1-800-867-5808.

  • For oral complaints: Call the Gila River RBHA at this toll free telephone number: 1-888-484-8526.
  • To submit a written complaint: Mail the complaint to the Gila River RBHA Director at the Hu Hu Kam Memorial Hospital, P.O. Box 38, Sacaton, AZ 85147.
  • All complaints must be acknowledged. Complaints filed orally shall be considered acknowledged at the time of filing. Written complaints must be acknowledged to the complainant within 5 working days of receipt by the T/RBHA.

The T/RBHA complaint process must:

  • Educate and notify persons about their rights and the process for filing complaints appeals and SMI grievance/investigations in a manner that is understandable, including providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability;
  • Handle any complaints which involve potential fraud or abuse in accordance with applicable agency reporting requirements;
  • Promptly identify and resolve complaints in the most expeditious and equitable manner with due regard for the dignity and rights of all persons;
  • Maintain confidentiality and privacy of complaint matters and records at all times.
  • Communicate, as appropriate, information on matters and decisions related to the complaint to affected parties, in a timely manner;
  • Involve the active cooperation and participation as deemed appropriate of providers with a direct interest in the matter under review'
  • Provide education and training to T/RBHA and provider staff regarding member rights and the complaint process, including the obligation to report suspected right’s violations of persons determined to have a Serious Mental Illness pursuant to 9 A.A.C. 21-403(C);
  • Be centralized within the organization, (regardless of whom within the organization receives the complaint or whether the complaint is filed orally or in writing), in order to track the types and volume of complaints and identify potential deficiencies in the delivery system for which corrective action plans can be developed; and
  • Refrain from referring complainants to AHCCCS Administration for issues related to the ADHS/DBHS service delivery system.

How long does the T/RBHA have to resolve a complaint?
T/RBHAs are required to dispose of each complaint and provide oral or written notice as expeditiously as the issue or health condition requires. Most complaints should be resolved within 10 days, but should in no case exceed 90 days from the day the T/RBHA receives the complaint.

Who makes decisions regarding a complaint?
The T/RBHA must ensure that the individuals who make decisions regarding complaints are not involved in any previous level of review or decision-making. Individuals must be health care professionals with the appropriate clinical expertise in treating the member's condition when making a decision regarding:

  • A complaint related to the denial of expedited resolution of an appeal; or
  • Complaints involving clinical issues.

What needs to be in the complaint record?
At a minimum, the complaint record must include the following documentation:

  • The date the complaint was made;
  • The member’s first and last name;
  • Title XIX/XXI eligibility status;
  • The behavioral health enrollment category: SMI, GMH, Child/Adolescent, Substance Abuse treatment, not enrolled;
  • The name of the person making the complaint;
  • A description of the complaint;
  • Any identified communication needs;
  • The date that the complaint was acknowledged to the originator of the concern;
  • All steps utilized during the investigation of the complaint and of the resolution;
  • Steps taken to assist in ensuring immediate health care needs are met;
  • The date the resolution was communicated to affected parties, in accordance with confidentiality requirements;
  • Implemented corrective action plan(s) or action(s) taken to resolve the concern(s);
  • Supporting evidence that the resolution was implemented; and
  • Evidence that identified issues were referred, as indicated, to the appropriate committees, departments, and regulatory agencies.

Complaint records must be maintained for a minimum of six years from the date of resolution or disposition.

What if the complainant is not satisfied with the resolution to the complaint?
The T/RBHA will notify the complainant of further alternatives if they are dissatisfied with the complaint determination, including the option to contact AHDS/DBHS at 602-364-4558.

What is the role of contracted providers?
The T/RBHA and contracted providers must be available to assist a person in the filing of a complaint and must not retaliate against any persons who file such complaints. Providers are also expected to cooperate and participate as requested by the T/RBHA in the resolution of complaints.

All T/RBHAs are required to have on staff a customer services manager who is responsible for coordinating communications with eligible and enrolled persons and coordinate with advocates, service providers, internal staff resources, and others to resolve issues.

5.2.4 References
The following citations can serve as additional resources for this content area:

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5.2 Member Complaints
Last Revised: 12/20/2013
Effective Date: 12/20/2013

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