At Colorado Health Networks (CHN), we care about you and the quality of services that you get. We work hard to give you the best care. We always try to improve the way we serve you. We want you to give us feedback about how well we are doing.

We also know that problems happen. If you are unhappy with any part of your mental health treatment, you have the right to file a grievance, or appeal an action. CHN can help you with filling out forms. CHN can help you understand how to file a grievance or appeal.

Definitions

Action: an action can be any of the following:

• All or part of treatment is denied.
• Reduce, change, or end treatment that was already approved.
• Failure of provider to act within approved timeframes.
• Denial of request to obtain treatment outside the network, in rural areas.
• Failure to provide treatment in timely manner.

Appeal : the request for review of an action.

Grievance : Stating (in writing or telling another person) that you are unhappy about any matter other than an action. This may include quality of care or services we provide. Or being unhappy with the people who care for you such as rude providers or employees, or not respecting your rights.

“What can I file a grievance about?”

You can file a grievance for any reason that is related to the services you get for a mental health issue. If you have a concern about your services (such as being unhappy with your appointment times, rude staff, or similar issues), please see the section below titled, “How do I file a grievance?” If you would like to ask for a review of an action, see the section titled, “How do I appeal an action?” below.

If you need help filing a grievance or an appeal, please ask the consumer or family advocate at your mental health center. You can also call the Colorado Health Networks Grievance Coordinator at 1-800-804-5040. You can also call the Ombudsman for Medicaid Managed Care at 877-435-7123

“How do I file a grievance?”

There are several ways to file a grievance:

• Talk to the consumer/family advocate at your community mental health center. The phone numbers to the mental health centers are on pages 26-28.

OR

• Call the Grievance Coordinator at Colorado Health Networks at: 1-800-804-5008. You can write to:

OR

• Call the Ombudsman for Medicaid Managed care at: 1-877-435-7123

You must make your grievance within 20 calendar days from when the event happened. You can make your grievance by writing us a letter. You can talk to a person at the local mental health center. You can also choose someone to make the grievance for you.

 “What happens next?”

Once we get the grievance, the Office of Consumer and Family Affairs, consumer/family advocate, or other appropriate people will look into the grievance. We will mail you a letter in 2 days, telling you we got your grievance. Based on what we learn, we will make a decision about your grievance. This process is confidential. You or your family member will not lose your Medicaid benefits.

Next, we will mail you a written notice of our decision. We will mail the notice within 15 working days after we get your grievance. This letter will also tell you what to do if you do not agree with our decision.

“What if I disagree with your decision about my grievance?”

If you are unhappy with the answer you get about your grievance, you can either call or write the Plan Manager at the State. They are at:

Medicaid Plan Manager
Department of Health Care Policy and Financing
1570 Grant Street
Denver , CO 80203-1818
(800) 221-3943, extension 2345

The Plan Manager will let you know he/she received the grievance. Then they will make a decision. The decision that the Plan Manager makes will be final.

“How do I appeal an action?”

If you disagree with a notice of action (defined in the section titled, “Grievances and Appeals”), you have the right to file an appeal.

You must make your appeal within 20 calendar days from when we sent the notice of action. You can make your appeal by writing a letter. Or you can talk directly to a person such as a care manager. A provider or other person you choose can make an appeal on your behalf. If so, you have to give written consent for that person to represent you. An expedited appeal process is available if the standard time for resolving an appeal would cause harm.

To file an appeal, call the Colorado Health Networks Care Management Department. You can call them at 1-800-804-5008. You can also write to them.

Colorado Health Networks
Care Management Department
7150 Campus Drive, Suite 300
Colorado Springs , CO 80920

You can also file an appeal with the Office of Administrative Courts. You can call them at: 303-866-2000.

“What happens next?”

If you appeal to Colorado Health Networks , we will send you a letter to let you know we got your appeal. We will do this within two working days. The letter will also tell you more about the appeal process.

We will make a decision within ten calendar days. If we need more time to make a decision, we will send you a letter telling you why we need more time. The letter will also tell you when to expect a decision. When we make the decision, we will send you a letter. We will also try to call you on the telephone. For an expedited appeal, we will make the decision and send you the notice (and call you on the phone, if possible) within three working days of the date we received the expedited appeal.

If you appeal to the Office of Administrative Courts , you can ask for a State fair hearing. This is your right. You can do this any time during the appeal process. You must make this request within 20 calendar days from the date you got the Notice of Action from Colorado Health Networks. This notice is described in the, “How do I appeal an action?” section above.

If you ask for an appeal or a State fair hearing, your benefits will continue if the request is received within the required timeframes and you ask for your benefits to continue. If your appeal is denied, you may have to pay for the cost of services you received while your appeal was being reviewed.

“What else do I need to know?” 

There may be times when you want to file your grievance or appeal with the Ombudsman for Medicaid Managed Care. They can help you file your grievance or appeal. Contact them at:

Ombudsman for Medicaid Managed Care
877-435-7123 outside of Denver
303-830-3560 in the Denver Metro area.
888-876-8864 (TTY) for hearing impaired

You may want to file for a fair hearing directly with the Office of Administrative Courts. This your right. For the appeal of an action, you can call or write them directly at any time during the process. There is more information on the next page about these two agencies.

Office of Administrative Courts
633 17 th Street Suite 1300
Denver , CO 80202
303-866-2000

Ombudsman for Medicaid Managed Care

The Ombudsman for Medicaid Managed Care can help you with grievances, appeals or other mental health quality issues.

There is no cost to you for using this program. Any Medicaid member who lives in Colorado can use them. Any member who has received mental health services in Colorado can use them. If you would like to talk to someone at the Ombudsman Program, call 877-435-7123 if you live outside of Denver. Call 303-830-3560 if you live in the Denver Metro area. TTY: (888) 876-8864

Office of Administrative Courts

 At any time during the appeal process you may ask for a fair hearing of your appeal. This is your right. You must make the request in writing. We encourage you to go through the appeal process first to try to resolve the problem. If you choose to file an appeal with the Office of Administrative Courts, you should mail it to:

Office of Administrative Courts
633 17 th Street Suite 1300
Denver , CO 80202
303-866-2000