Or. Admin. Code § 309-022-0190

Current through Register Vol. 63, No. 12, December 1, 2024

Section 309-022-0190 - Grievances and Appeals

(1) Any individual receiving services or the parent or guardian of the individual may file a grievance with the provider, the individual's managed care plan, or the Division.

(2) Medicaid grievances and appeals shall adhere to procedures set forth in OAR 410-141-0260 through 410-141-0266.

(3) For individuals whose services are not funded by Medicaid, providers shall:

(a) Notify each individual or guardian of the grievance procedures by reviewing a written copy of the policy upon entry;

(b) Assist individuals and parents or guardians, as applicable, to understand and complete the grievance process and notify them of the results and basis for the decision;

(c) Encourage and facilitate resolution of the grievance at the lowest possible level;

(d) Complete an investigation of any grievance within 30 calendar days;

(e) Implement a procedure for accepting, processing, and responding to grievances including specific timelines for each;

(f) Designate a program staff person to receive and process the grievance;

(g) Document any action taken on a substantiated grievance within a timely manner; and

(h) Document receipt, investigation, and action taken in response to the grievance.

(4) The provider shall have a grievance process notice that shall be posted in a conspicuous place stating the telephone number of:

(a) The Division;

(b) The CMHP;

(c) Disability Rights Oregon; and

(d) The applicable managed care organization.

(5) When the matter of the grievance is likely to cause harm to the individual before the grievance procedures are completed, the individual or individual's guardian may request an expedited review. The program administrator shall review and respond in writing to the grievance within 48 hours of receipt of the grievance. The written response shall include information about the appeal process.

(6) A grievant, witness, or staff member of a provider may not be subject to retaliation by a provider for making a report or being interviewed about a grievance or being a witness. Retaliation may include but is not limited to dismissal or harassment; reduction in services, wages, or benefits; or basing service or a performance review on the action.

(7) The grievant is immune from any civil or criminal liability with respect to the making or content of a grievance made in good faith.

(8) Individuals and their legal guardians shall have the right to appeal entry, transfer, and grievance decisions as follows:

(a) If the individual or guardian is not satisfied with the decision, the individual or guardian may file an appeal in writing within ten working days of the date of the program administrator's response to the grievance or notification of denial for services. The appeal shall be submitted to the CMHP Director in the county where the provider is located or to the Division;

(b) If requested, program staff shall be available to assist the individual;

(c) The CMHP Director or Division, shall provide a written response within ten working days of the receipt of the appeal; and

(d) If the individual or guardian is not satisfied with the appeal decision, they may file a second appeal in writing within ten working days of the date of the written response to the Director.

Or. Admin. Code § 309-022-0190

MHS 8-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 5-2014, f. & cert. ef. 2-3-14; BHS 16-2018, temporary amend filed 07/17/2018, effective 08/01/2018 through 01/27/2019; BHS 24-2018, amend filed 12/27/2018, effective 1/25/2019

Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 426.490 - 426.500, 428.205 - 428.270, 430.640 & 443.450

Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 413.520 - 413.522, 426.380 - 426.395, 426.490 - 426.500, 430.010, 430.205 - 430.210, 430.240 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991 & 743A.168