Last Modified Date – 11/01/2022

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Grievances & Appeals

Last Modified Date – 11/01/2022

A grievance is a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished.

 

Notification to Participants: Upon enrollment, and at least annually thereafter, Rocky Mountain PACE must give a participant written information on the grievance process.

 

Grievance Process

Rocky Mountain PACE has a formal written process to evaluate and resolve medical and non-medical grievances by participants, their family members, or representatives.

How a participant files a grievance:

  • The participant and/or his/her caregiver may either write or discuss a grievance with any staff member at Rocky Mountain PACE or a member of the Quality and Compliance Department.
  • Grievance forms are located with the secured Grievance boxes in the lobby and the Day Center. Once the form is completed, it may be placed in the secured box, or it can be handed to any staff member who will deliver it to the Quality and Compliance department.

Documentation of a participant’s grievance:

  • The grievance will be logged and followed by the Quality and Compliance Department at Rocky Mountain PACE.

Response to and resolution of a grievance in a timely manner:

  • We make every attempt to reach the participant/caregiver in a timely manner by phone to discuss the proposed resolution.

Maintenance of confidentiality of a participant’s grievance:

  • Throughout the grievance process, the Quality and Compliance Department will maintain the confidentiality of the participant’s grievance.

Continuing care during the grievance process:

  • Rocky Mountain PACE must continue to furnish all required services to the participant during the grievance process.

Explaining the grievance process:

  • All participants/caregivers will receive a letter with specific steps outlining the proposed resolution regardless of whether we were able to reach them by phone. Our policy outlines that we must contact the participant and/or caregiver with the proposed resolution within 30 calendar days.

 

Analyzing grievance information. The PACE organization must maintain, aggregate, and analyze information on grievance proceedings. This information must be used in Rocky Mountain PACE’s internal quality improvement program.  Rocky Mountain PACE has systems in place to maintain, aggregate, and analyze data from multiple sources.  The grievance process actively incorporates input from staff, participants, caregivers/families, contracted providers, and others as appropriate. The process also includes using performance indicators to monitor a wide range of medical and non-medical processes and outcomes and reviewing findings against benchmarks and/or goals the organization has established for performance. The approach includes maintaining, aggregating and analyzing adverse events every time they occur, and action plans implemented by utilizing project improvement forms to prevent recurrences and uphold safety.

The Quality Improvement (QI) team will determine which areas to monitor routinely and will determine potential projects based on data. The QI team reviews sources of information to determine if gaps or patterns exist in systems of care that could result in quality problems or if there are opportunities to make improvements.  On a quarterly and annual basis, the QI program is evaluated by the committee and governing body to ascertain the effectiveness of the quality improvement process, strengths, accomplishments, and opportunities for improvement.

 

Rocky Mountain PACE

Attn: Quality & Compliance Department

2502 East Pikes Peak Ave Suite 100

Colorado Springs, CO  80909

Phone: (719) 314-2327 Ext. 856

TTY 800-659-2656 Ext. 856

Fax: (719) 314-0077

Click here to download and complete the Participant Grievance Form.

Standard Appeals Process:

An appeal is a participant’s action taken with respect to Rocky Mountain PACE’s noncoverage of or nonpayment for a service including denials, reductions, or termination of services.

Notification to Participants: Upon enrollment, at least annually thereafter, and whenever the interdisciplinary team denies a service determination request or request for payment, the PACE organization must give a participant written information on the appeals process.

All of the staff at Rocky Mountain PACE share responsibility with you, your family or your caregiver in providing you the comprehensive health care services identified in your Plan of Care as authorized by the Interdisciplinary Team. You, your family, or your caregiver are encouraged to contact a member of the Interdisciplinary Team when you have a disagreement with Rocky Mountain PACE’s noncoverage of or nonpayment for a service including denials, reductions, or termination of services.

If we deny your request for a noncoverage of, or nonpayment for a service including denials, reductions, or termination of services, we will give you a written copy of this information on the appeals process, including a form that you may use to request your appeal. You may also make your appeal known verbally, and PACE staff will document and submit your request for an appeal.

Appeals Process:

  •  Rocky Mountain PACE ensures timely preparation and processing of a written denial of coverage or payment.
  •  If a participant or their designated representative chooses to pursue an appeal, they may start the process by completing the Appeal Request Form and submitting to the Rocky Mountain PACE Quality and Compliance Department or by contacting the Rocky Mountain Quality and Compliance Department over the phone so that we can receive the appeal request orally.
  • Rocky Mountain PACE will thoroughly document the appeal process as they help facilitate the process.
  • Appeals are reviewed by an appropriate third-party reviewer or committee. The third-party reviewer is appropriately credentialed in the field(s) or disciplines(s) related to the appeal, was not involved in the original action, and does not have a stake in the outcome of the appeal.
  • The distribution of written or electronic materials to the third party reviewer or committee will contain, at minimum: Service that must be provided in a manner consistent with federal requirements, the need to make decisions in a manner consistent with how determinations under the Social Security Act are made, and the rules in the Federal Code that specify that certain limitations and conditions applicable to Medicare or Medicaid or both benefits do not apply.
  • Rocky Mountain PACE responds to and provides resolution of appeals as expeditiously as the participant’s health condition requires, but no later than 30 calendar days after Rocky Mountain PACE receives an appeal.
  • Rocky Mountain PACE gives all parties involved in the appeal a reasonable opportunity to present evidence related to the dispute in person, as well as in writing.
  • During the appeals process, Rocky Mountain PACE will continue to furnish the disputed services until issuance of final determination if Rocky Mountain PACE is proposing to terminate or reduces services currently being furnished to the participant or if the participant requests continuation with the understanding that he or she may be liable for the costs of the contested services if the determination is not made in his or her favor. Rocky Mountain PACE will also provide all other required services.
  • Rocky Mountain PACE does have an expedited appeals process for situations in which the participant believes that his or her life, health, or ability to regain or maintain maximum function could be seriously jeopardized, absent provision of the service in dispute. Rocky Mountain PACE will respond to expedited appeals as expeditiously as the participant’s health condition requests but no later than 72 hours after it receives the appeal. Rocky Mountain PACE may extend the 72-hour timeframe by up to 1 calendar day if the participant requests the extension or if Rocky Mountain PACE justifies to the State administering agency the need for additional information and how the delay is in the interest of the participant.
  • Rocky Mountain PACE will give all parties involved in the appeal appropriate written notification of the decision to approve or deny the appeal.
  • Following a favorable decision, Rocky Mountain PACE will furnish the disputed services as expeditiously as the participant’s health condition requires.
  • Rocky Mountain PACE maintains, aggregates, and analyzes the information on appeal proceedings and uses this information in the Rocky Mountain PACE internal quality improvement program.

 

Click here to download and complete the Request to Appeal Form.

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