Keeping Us Informed

It is important that you let us know important changes to help us better serve you. Please keep the following in mind:

• Notify your local Department of Human Services (DHS) of any change in family size, name or address.
• Notify us of any change of address. If you move out of the region or out-of-state, we can assist you in transferring your records.
• Notify us of any changes in your insurance coverage.

If you lose your Medicaid insurance, and you are receiving services, you will continue to receive services or supports for as long as they are necessary.

How Authorizations Are Handled

Services you request must be authorized by the PIHP. There are time frames for these authorizations. You will receive notice of authorizations within 14 days for standard authorizations and 3 days for expedited authorizations. If Venture denies your request for a service, or decreases the amount of service you will be getting by way of an “action”, you will be told of this decision at the time it is requested or sent notice of this within 12 days before your service is affected.

Any decision that denies authorization of a service you request or denies the service in the amount, duration or scope that is less than requested will be made by a health care professional who has appropriate clinical expertise in treating the member’s condition. Authorizations will be made according to medical necessity. If you do not agree with a decision to deny, reduce, suspend, or terminate a service you may file an appeal at your local CMHSP, with Venture, and/or file an appeal with the Michigan Administrative Tribunal and request a State Fair Hearing. See below how you would do this.

Grievance and Appeals Process

We want you to feel comfortable talking with your service provider if you have a problem. If you are unable to solve the problem with your provider, and your problem is not about an “Action”, you can make a f ormal “Grievance” with a Member Services Representative.

If your problem is about an “Action” regarding a “Covered State Plan Service”, then you may make a formal “Appeal” to your local CMHSP, to Venture, and/or to the Michigan Administrative Tribunal. You may file appeals with each one individually, or with all three at the same time. Your provider and/or Venture must help you every step of the way.

If your appeal is about an “Action” regarding an “Alternative Service” you cannot appeal to the Administrative Tribunal for a State Fair Hearing, however, you are able to have a “Local Dispute Resolution Conference”. You are still able to appeal at your local level CMHSP and/ or with Venture.

Forms to request an Administrative Tribunal State Fair Hearing are available at your local Community Mental Health Center. Your service provider or the Member Services Representative will help you to complete this form or call and make a verbal complaint/appeal. The provider will help you through the entire process.

You have the right to have all the services you are receiving, or need to receive, to continue being provided while you appeal the PIHP’s decisions. Your benefits will be reinstated if you request a local level appeal or State Fair Hearing within 12 calendar days from the date of the notice of “action”. You may be asked to pay a portion of the services you received during the Grievance and Appeals process if you lose the Grievance or Appeal. This is NOT always true, but if you need to pay you will be notified of the amount.

You have the right to have a provider, acting on your behalf and with your written consent, file an appeal locally and/or with Venture. Your Provider can only file a grievance or ask for a State Fair Hearing, if the State of Michigan permits your provider to act as your authorized representative.

If you need help, please contact your Member Services Representative listed on the last page of this handbook.

Timelines For a Grievance or Appeal

Grievance

If you have a grievance you can file this at any time with your local CMHSP Grievance and Appeal officer. They will respond in writing within 60 calendar days with an explanation of what has been done about your grievance. If you do receive this within 60 days, your grievance is then considered an “action” and you are then allowed to have a local level appeal and/or a State Fair Hearing.

Local Appeal

If you, a representative for you, or your provider, are appealing an “action” against you, you must do this within 45 calendar days of the date of the notice of “action”. This request must be confirmed in writing if you are not requesting an expedited resolution. You will receive written notice of the results of the appeal within 45 days from the date you filed it, unless you have asked for an expedited appeal, in which case, you will be told within 3 days.

State Fair Hearing

If you would like a State Fair Hearing, you have 90 days from the date of the “action” to request this. You do not have to exhaust the local level of appeals before doing this.

A Member Service Representative will help you if you would like to file an appeal with the State of Michigan or you can contact the Michigan Department Of Community Health, Administrative Tribunal at:

Administrative Tribunal
Michigan Department Of Community Health
P.O. Box 30195
Lansing , MI 48909
1 (877) 833-0870

Need Help Filing a Grievance or Appeal?

If you would like help understanding what your rights are to filing a grievance or appeal, or would like assistance in filing one, please contact your local Member Service Representative, or contact Venture’s Member Service Department, all listed at the back of this handbook.

Member Rights & Responsibilities

Venture Behavioral Health is committed to providing you the best service based upon your needs. As a member, you have certain rights and responsibilities and it is important that you understand them.

You You have the right :

• To be treated with respect and dignity.
• To convenient and timely access to services.
• To get help fast and in a respectful way.
• To use any hospital or other setting for emergency care.
• To be given information about your benefits, any limitations with the service network and any cost that you will have to pay.
• To be involved in deciding what services you will receive , and to decide whether family members and others should be involved as well .
• To decide whether you would like family members and others to be a part of your plan of care.
• To be told about the kinds of services that you may receive be told about the kinds of services that you may receive and know who is available to provide services .
• To receive information on available treatment options and alternatives.
• To choose who will provide you your service .
• To have interpretation service provided for you at no cost to you if English is not your chosen language or you have hearing impairments.
• To refuse services and be told about the possible results of that decision.
• To express preferences about future treatment decisions.
• To be aware of and use advocates (people who will help you) whenever you feel they are needed.
• To be free from restraint or seclusion as coercion, discipline, provider convenience or retaliation.
• To receive services in a safe, clean, and caring place.
• To express a complaint about Venture Behavioral Health, its providers and/or the quality of care that you receive, and to have that complaint addressed in a timely manner.  
• To see or receive a written copy of your record or chart and make changes if necessary to it. 

A member, who is a child, has the right to be represented by a parent, legal guardian, or custodial agency in the development or revision of the plan of care. 

• To have all of your needs handled in a confidential way. Your written permission will always be needed to release any information about you, except when:
  1. Medicaid or the State asks for clinical information.
  2. There is suspected abuse or neglect (child or adult), as mandated by State law.
  3. You or someone else is determined to be in immediate danger
  4. To make a grievance about services and have that grievance resolved quickly.
• To file an appeal with the PIHP, CMHSP, and/or Michigan Department of Community Health.
• To have a provider, on your behalf and with written consent, file an appeal with the PIHP and/or CMHSP.
• To have a second opinion from a qualified health professional, within our provider network, or out of our provider network, at no cost to you.
• To receive practice guidelines upon request.
• To additional information upon request concerning:
  • The structure and operation of the PIHP
  • Physician incentive plans

Venture Behavioral Health does not prohibit health care professionals from discussing health status, medical care, treatment options (including alternative treatment that may be self administered) as well as risks, benefits, and consequences of treatment or non-treatment.

You have the responsibility:

• To present your Medicaid card and/or other insurance coverages prior to receiving services.
• To keep scheduled appointments and let the office know if you will be delayed or unable to keep your appointment, if possible, at least 24 hours in advance.
• To let us know of a change in name, address, or insurance coverage.
• To pay all charges that have been determined you may owe.
• To make payments for services on time.
• To ask questions about your services and keep asking until you fully understand.
• To provide honest and complete information to those providing services.
• To follow the plan of care you chose, and to understand what might happen if you choose to not follow the plan.
• To know what medications you are taking, why you are taking it, the proper way to take it and possible side effects of that medicine.
• To express your opinions, concerns or complaints in a constructive manner.