uI POLICY/PROCEDURE DEPARTMENT OF MENTAL …

1 %. O: LOS1. DEPARTMENT OF MENTAL health . uI POLICY/PROCEDURE . 4 CIForL'. SUBJECT POLICY NO. EFFECTIVE PAGE. DATE. REQUEST FOR CHANGE OF 06/18/2018 1 of 5. PROVIDER. APPROVED BY: SUPERSEDES ORIGINAL DISTRIBUTION. 2 1v-1. ISSUE DATE LEVEL(S). 5_' %. Director 08/29/2016 01/01/2003 1, 2. 1. P4 WPOSE. 1 .1 Provide a formal process for beneficiaries to request a change in program of service or rendering staff. 1 .2 Comply with the California DEPARTMENT of health Care Services (DHCS), MENTAL health Services Division's (MHSD) requirement that Local MENTAL health Plans (LMHP5) submit a summary report of voluntary change of provider requests from Medi-Cal beneficiaries seen through the LMHP. (Authorities 1 2, 3, 4, and 5). , DEFINITION.

2 Provider: Person or entity who is licensed, certified, or otherwise recognized or authorized under state law governing the healing arts to provide specialty MENTAL health services and who meets the standards for participation in the Medi-Cal program. (Authority 6)..1 Program of Service: A specific location and/or provider..2 Practitioner: Staff who provides services to beneficiaries ( , psychiatrist, psychologist, nurse, psychiatric social worker, case manager, therapist, etc.). Voluntary Change of Provider: Only changes of program of service and/or practitioner, resulting from beneficiary requests constitute voluntary changes of provider. The following occurrences do not constitute a voluntary change of provider: A beneficiary changes program of service due to staff turnover, staff reorganization, or termination of a provider contract.

3 (o: Los DEPARTMENT OF MENTAL health . POLICY/PROCEDURE . kw;1. CIFO& . SUBJECT POLICY NO. EFFECTIVE PAGE. DATE. REQUEST FOR CHANGE OF 06/18/2018 2 of 5. PROVIDER. A beneficiary moves to a different geographic area within the County and, therefore, changes program of service and practitioner;. A beneficiary changes program of service from a child to an adult provider; and A beneficiary is discharged from the system. Grievance: A beneficiary's verbal or written expression of dissatisfaction about any matter other than an Adverse Benefit Determination. Grievances include, but are not limited to, quality of care or services provided and aspects of interpersonal relationship with provider of the Los Angeles County DEPARTMENT of MENTAL health (LACDMH).)

4 POLICY. LACDMH recognizes that beneficiaries have the right to request change in program of service and/or practitioner to achieve maximum benefit from MENTAL health services. Every effort shall be made to accommodate such requests. LACDMH shall report to DHCS, no later than October 1st of each year, the number of Medi-Cal beneficiaries who request a voluntarily change of provider during the fiscal year. The report shall be based on data from the prior fiscal year. (Authorities 1 and 4). LACDMH shall report to DHCS, no later than October 1st of each year, the number of grievances raised through the LMHP's beneficiary problem resolution process. (Authorities 1 and 3). LACDMH's Quality Improvement Division shall review data from Patients' Rights Office (PRO) regarding voluntary change of provider requests on a quarterly and annual basis.

5 Appropriate action shall be taken based on the data..( o' LOs1. DEPARTMENT OF MENTAL health . fl:) POLICY/PROCEDURE . - SUBJECT POLICY NO. EFFECTIVE PAGE. DATE. REQUEST FOR CHANGE OF 06/18/2018 3 of 5. PROVIDER. PROCEDURE. Beneficiaries may request a program of service and/or practitioner change by completing and submitting the Request for Change of Provider form. (Attachment 1). Request for Change of Provider forms (Attachment 1) are available upon request at program of service locations or can be downloaded directly from the LACDMH website..2 Beneficiaries may request assistance with completing the Request for Change of Provider form from any MENTAL health staff or PRO advocate..3 Completed Request for Change of Provider forms shall be submitted to clinic staff.

6 4 Clinic staff shall sign Request for Change of Provider forms upon receipt and provide beneficiaries with a copy. (Attachment 1 Page 1). , Program managers shall attempt to accommodate all beneficiary requests to change program of service and/or practitioner. The beneficiary is under no obligation to provide any reasons for his/her request to change program of service location or practitioner. However, in order to improve the quality of programs and understand the nature of the request, program managers shall attempt to obtain information regarding the request from the beneficiary. The program of service may be able to clarify a misunderstanding or resolve a concern at a level that is satisfactory to the beneficiary. The beneficiary may, at this time or any other, rescind the request.

7 Frequent or repeated requests or an insufficient number of practitioners are examples of reasons why program managers may not be able to accommodate a beneficiary with a change of provider. Program Managers shall document the reasons. % & LOSdl , DEPARTMENT OF MENTAL health . +14j [!+z : . POLICY/PROCEDURE . \ . SUBJECT POLICY NO. EFFECTIVE PAGE. DATE. REQUEST FOR CHANGE OF 06/18/2018 4 of 5. PROVIDER. Within 10 working days of receiving a Request for Change of Provider form, program manager shall attempt to verbally notify the beneficiary of the outcome, followed by the appropriate written confirmation. (Attachments 2 and 3). The appropriate written confirmation of notification shall be maintained in a separate administrative file and retained for 10 years.]

8 If the beneficiary is not satisfied with the outcome of the request, he/she may pursue the LMHP's beneficiary problem resolution process (Authority 7) and file a grievance. A beneficiary requesting to change a LMHP program of service shall contact PRO. Within 10 working days of receiving the request, PRO shall provide the beneficiary with names of alternative programs of service in the area of choice. Providers shall maintain Request for Change of Provider forms received from beneficiaries. All submitted Request for Change of Provider forms shall be collected by the Program Manager at the end of each workday and maintained in a separate administrative file. Request for Change of Provider forms shall be retained by the program managerfor 10 years.

9 Request for Change of Provider forms shall be reviewed by the agency's Quality Improvement Council to determine if there are any trends present. Program manager or designee shall enter the information collected on Request for Change of Provider forms into the Public Facing Request for Change of Provider Database (PFCOP). By the 10th of each month, each program of service shall enter all requests or no request into the PFCOP. 5: io .. DEPARTMENT OF MENTAL health .. I. 4 LlfQR'. ; ! POLICY/PROCEDURE . SUBJECT POLICY NO. EFFECTIVE PAGE. DATE. REQUEST FOR CHANGE OF 06/18/2018 5 of 5. PROVIDER. AUTHORITY (HYPERLINKED). 1. California Code of Regulations Title 9 Section 2. California Code of Regulations Title 9 Section 3. California Code of ReQulaflons Title 9 Section 4.

10 California DEPARTMENT of health Care Services MENTAL health Services Division, Program Oversight and Compliance, Annual Review Protocol for Specialty MENTAL health Service and Other Funded Services, Section B Access 4.. 5. California DEPARTMENT of health Care Services MENTAL health Services Division, Program Oversight and Compliance, Annual Review Protocol for Specialty MENTAL health Service and Other Funded Services, Section D Beneficiary Protection 2.. 6. California Code of Regulations Title 9 Section 7. LACDMH Policy No. , Beneficiary Problem Resolution Process ATTACHMENT (HYPERLINKED). 1 Request for Change of Provider . English Spanish 2. Response Letter Sample for Change of Provider Request Not Granted English Spanish 3.