Problem Resolution Process

Monterey County Behavioral Health (MCBH) is committed to finding solutions to the problems and concerns you may encounter during the course of receiving services with us. Members will not be subjected to discrimination, intimidation, or any other retaliation for expressing concerns, filing a grievance, appeal, or State Fair Hearing. If you are unhappy with any issue related to the services you are receiving, you have options that may help you with the resolution of these issues. Here are some options for you to consider when deciding the next steps to take.

Change of Clinician

The form is located in all outpatient clinic lobbies. The form is used to request a change in psychiatrist, psychologist, social worker, or case manager.

How do I ask for a change of clinician?

You may complete the Change of Clinician form and submit it to any MCBH staff.

What happens after I complete this form?

The form will be reviewed by the Program Manager and/or Behavioral Health Unit Supervisor. You may receive a telephone call from the Program Manager and/or Behavioral Health Unit Supervisor requesting further information and/or to begin the process of identifying solutions. The solutions may vary from person-to-person as each situation is unique.

Grievance

What is a Grievance?

A grievance is an expression of unhappiness or dissatisfaction with MCBH and it does not involve an Adverse Benefit Determination. Members also have the right to submit a grievance for failure to provide trans-inclusive care.

Who can file a Grievance?

The member who receives services through MCBH, a provider, and/or authorized representative.

What is the deadline to file a Grievance?

There is no deadline to file a grievance and a member may file a grievance at any time, but it is best to do it soon after the issue arises in order to provide more specific and detailed information.

How do I file a Grievance?

The member, provider, or authorized representative may file a grievance either orally, inwriting, or in person at the following address and/or phone number:

Monterey County Behavioral Health
Quality Department
1611 Bunker Hill Way, Suite 120
Salinas, CA 93906
(831) 755-4545 / (831) 796-1788 TTY/TDD

Where do I obtain the grievance form?

The grievance form is located within the following link, at the very bottom of the page, under Forms. Additionally, you may request a copy of the form at the location where you receive services, from any of your treatment team members, or by calling Quality Improvement at (831) 755-4545.

When will I receive information back about a Grievance I filed?

You will receive written acknowledgement from MCBH that your grievance was received within 5 calendar days. MCBH will make a decision about your Grievance within 30-calendar days from the date we receive your grievance.

Notice of Adverse Benefit Determination (NOABD)

What is a Notice of Adverse Benefit Determination (NOABD)?

A Notice of Adverse Benefit Determination (NOABD) is a form you receive from MCBH that gives you information about a decision or “action” that was made about why you are not eligible to receive or to continue to receive Medi-Cal specialty mental health and/or substance use disorder services. The form will give you specific information on:

The specific reason the decision was made.
Information about what your rights are if you do not agree with the decision.
Information about the Grievance, Appeal, or Expedited Appeal process.
Information on the State Fair Hearing process.
Information on the deadlines to request a grievance, appeal, expedited appeal, or State Fair Hearing process.

What are “actions” by the Behavioral Health Plan?

An “action”, also known as an Adverse Benefit Determination, occurs when the BHP does at the least one of the following:

Denies or limits authorization of requested services, including the type and level of service; medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
Reduces, suspends or terminates a previously authorized service;
Denies in whole or in part, payment for the service
Fails to provide services in a timely manner
Fails to act within the time frames for the disposition of grievance and/or the resolution of expedited appeals
The denial of a beneficiary’s request to dispute financial liability.

What should I do if I get a Notice of Adverse Benefit Determination (NOABD)?

Read all the information on the form.
Pay close attention to the information regarding the timeline you have to file a grievance, appeal, expedited appeal, and State Fair Hearing.

What should I do if I do not agree with the decision described in the Notice of Adverse Benefit Determination (NOABD)?

You may file an Appeal.

Appeals Process

An Appeal is a request for a review of a problem you have with the mental health plan regarding a denial or changes in your mental health services as mentioned in the NOABD section above.

Who can file an Appeal?

The appeal may be filed by a member, a provider, or authorized representative. The appeal may be filed either orally, in writing, or in person AND any appeal filed by the provider on behalf of the member requires a written consent from the member.

What is the deadline to file an Appeal?

You must file an Appeal within 60 days from the date the action or decision was taken. This usually means the date on the NOABD.

Where do I obtain the appeal form?

The appeal form is located within the following link, at the very bottom of the page, under Forms. Additionally, you may request a copy of the form at the location where you receive services, from any of your treatment team members, or by calling Quality Improvement at (831) 755-4545.

https://www.countyofmonterey.gov/government/departments-ah/health/behavioral-health/behavioral-health/about-us/problem-resolutionprocess#noard

There are two types of Appeals.

There is a Standard Appeal and an Expedited Appeal.

Standard Appeal

What is a standard Appeal?

An appeal is a request for a review of a problem you have with the behavioral health plan regarding a denial or changes in your services as mentioned in the NOABD section above.

You may file an appeal in writing, orally, or in person.
MCBH will send you a written acknowledgement that your appeal was received and is being processed within 5 calendar days.
MCBH will provide a written decision concerning the standard appeal within 30 from the date your appeal was received.

Expedited Appeal

What is an Expedited Appeal?

It is a faster way to decide an appeal. This type of appeal process is similar to the Standard Appeal, but an Expedited Appeal must meet certain requirements below:

You may request an Expedited Appeal orally and you do not have to put your request in writing.
If you think that waiting up to 30 days for a standard Appeal decision will jeopardize your life, health, or ability to attain, maintain, or regain maximum function.
If MCBH agrees that your Appeal meets the requirements for an Expedited Appeal, then MCBH will resolve your expedited Appeal within 72 hours from the date your Expedited Appeal was received.
- MCBH will notify you and all affected parties orally and in writing of the decision of the Expedited Appeal.
If MCBH decides that your Appeal does not qualify for an Expedited Appeal, MCBH will notify you right away (verbally) and in writing within two (2) calendar days from the date the Appeal was received.

How do I file a standard or expedited Appeal?

The appeal may be filed either in writing, orally, or in person at the following address and/or phone number:

Monterey County Department of Health
Quality Department
1611 Bunker Hill Way, Suite 120
Salinas, CA 93906
(831) 755- 4545
TTY/TDD: (831) 796-1788

Alternatively, you may also contact the Patient’s Rights Advocate at (831) 7554518 for questions regarding the appeal process. All forms and self-addressed envelopes are available in all outpatient clinic lobbies, or you may use a plain paper to write your request. This form must be signed and dated by you.

State Fair Hearing Process

What is a State Fair Hearing?

It is an independent review conducted by an administrative law judge to ensure you receive the services to which you are entitled under the Medi-Cal program. State fair hearings are conducted after the appeal decision, where there is a timely resolution failure, or other conditions.

What is the deadline to ask for a State Fair Hearing?

A member or authorized representative may request a State Fair Hearing within 120 days after receiving an appeal resolution letter informing that the Behavioral Health Plan is upholding an Adverse Benefit Determination or if your appeal wasn’t resolved within the specified time frames.

When can I ask for a State Fair Hearing?

If you have Medi-Cal, you may ask for a State Fair Hearing whether or not you use MCBH’s Appeal process and whether or not you have received a Notice of Adverse Benefit Determination. Generally, you would follow the Appeals process above, prior to requesting a State Fair Hearing.

When will a decision be made about my State Fair Hearing request?

After you ask for a State Hearing, it could take up to 90 days to decide your case and send you an answer.

Can I get a State Fair Hearing more quickly?

You may request an Expedited State Fair Hearing by calling 1-800-743-8525/TDD 1-800-952-8349 if you think that waiting up to 90 days for a decision on your case will jeopardize your life, health, or ability to attain, maintain, or regain maximum function.

The Department of Social Services, State Hearing Division, will review the request and decide if it qualifies for an expedited hearing.

If the Expedited Fair Heating is approved, a hearing will be held, and a decision will be issued within 3 working days of the date of receiving your request.

How do I ask for a State Fair Hearing?

You can ask for a State Hearing by phone, electronically, or in writing:

By phone: Call 1-800-743-8525. If you cannot speak or hear well, please call TTY/TDD 1-800-952-8349.
Electronically: You may request a State Hearing online. Please visit the California Department of Social Services’ website to complete the electronic form: