Member Informing Materials

What Is a Grievance? 

A grievance is any expression of dissatisfaction you have with your behavioral health services that is not covered by the appeal or State Fair Hearing process. This includes concerns about the quality of your care, how you are treated by staff and providers, and disagreements about decisions regarding your care. 

The grievance process will: 

1. Involve simple steps to file your grievance orally or in writing.
2. Allow you to approve another person to act on your behalf. This could be a provider or an advocate. If you agree to have another person act on your behalf, you may be asked to sign an authorization form, which gives the BHP or Partnership permission to release information to that person.
3. Make sure the results of the grievance are provided within the required timeline.

How and When to File a Grievance: 

1. You can file a grievance at any time if you are unhappy with the care you have received or have another concern regarding your BHP or Partnership.
2. You may call your county’s 24/7 toll-free Access Line at (530) 225-5252 at any time to receive assistance with a grievance. You can also call (530) 245-6750 to leave a voicemail about your grievance and you will be contacted back within 1 business day.
3. You can submit a grievance orally or in written form; grievances can be filed anytime. 

Where to obtain a Grievance Form: 

1. Grievance forms can be found at any Shasta County Behavioral Health Plan building and are self-addressed to be mailed or you can drop it in a locked box at the facility.
2. You can also print a form from the Shasta County website here: https://www.shastacounty.gov/health-human-services/page/member-informin…

If your grievance is with a Partnership provider:

1. You may file a grievance for substance use disorder services via one of the following three methods: Call Partnership at (855) 863-4155.; or
2. Mail your grievance (Partnership will provide self-addressed envelopes at all provider sites for you to mail in your appeal).
3. Submit your grievance by e-mail or fax. Refer to Partnership’s website at https://www.partnershiphp.org/Members/Medi-Cal/Pages/GrievanceAndAppeal… for additional information.

What Happens Next:

1. The BHP or Partnership is required to provide you with a written letter to let you know your grievance has been received within 5 calendar days of receipt. A grievance received over the phone or in person, that you agree is resolved by the end of the next business day, is exempt and you may not get a letter.
2. A decision or resolution about your grievance must be made by the BHP or Partnership within 30 calendar days from the date your grievance was filed.
3. When a decision has been made about your grievance, the BHP or Partnership will send you or your approved person a written notice of the decision.

The grievance form can be found in the supporting documents below

What is an Appeal

An appeal is when you do not agree with the behavioral health plan (BHP) or Partnership's decision for the behavioral health services you are currently receiving or would like to receive. You may request a review of the BHP or Partnership’s decision by using:

1. The standard appeal process
2. The expedited appeal process
3. The two types of appeals are similar; however, there are specific requirements to qualify for an expedited appeal stated below.

How Can I File an Appeal? 

1. You may file an appeal by calling your BHP’s toll-free phone number at (888) 385-5201. After calling, you will have to file a subsequent written appeal as well.
2. Mail your appeal (The BHP will provide self-addressed envelopes at all provider sites for you to mail in your appeal).
3. You must file an appeal within 60 calendar days of the date on the Notice of Adverse Benefit Determination. If you did not receive a Notice of Adverse Benefit Determination, then there is no timeline for filing. 

What If Your Appeal Is for Substance Use Disorder: 

1. You may file an appeal for substance use disorder services via one of the following three methods: Call Partnership at (855) 863-4155. After calling, you will have to file a subsequent written appeal as well
2. Mail your appeal (Partnership will provide self-addressed envelopes a tall provider sites for you to mail in your appeal). Note: If you do not have a self-addressed envelope, you may mail your appeal directly to the address in front of this handbook
3. Submit your appeal by e-mail or fax. Refer to Partnership’s website athttps://www.partnershiphp.org/Members/Medi-Cal/Pages/GrievanceAndAppeal… for additional information.

The Standard Appeal Process: 

1. You can file an appeal orally or in writing. Once filled, you will receive an acknowledgement of your appeal within 5 calendar days.
2. Filing an appeal will not cause you to lose your rights or services and will not be held against your provider in any way.
3. You can authorize another person (including a provider or advocate) to take action on your behalf.
4. Your benefits will continue upon request for an appeal within the required timeframe. Please note: This is 10 days from the date your Notice of Adverse Benefit Determination was mailed or personally given to you.
5. You do not have to pay for continued services while the appeal is pending even if the final decision of the appeal is in favor of the BHP or Partnership’s adverse benefit determination.
6. The decision-makers for your appeal are qualified and not involved in any previous level of review or decision-making.
7. You or your representative can review your case file, including medical records and other relevant documents.
8. You will have a reasonable opportunity to present evidence, testimony, and arguments in person or in writing.
9. You, your approved person, or the legal representative of a deceased member’s estate can be included as parties to the appeal.
10. You will receive written confirmation from your BHP or Partnership that your appeal is under review.
11. Inform you of your right to request a State Fair Hearing, following the completion of the appeal process. Please note: You will have 120 days from the date of the notice of appeal resolution. 

The Expedited Appeal Process: An expedited appeal follows a similar process to the standard appeal but is quicker.

1. You must show that waiting for a standard appeal could make your behavioral health condition worse.
2. The expedited appeal process follows different deadlines than the standard appeal process.
3. The BHP or Partnership has 72 hours to review expedited appeals.
4. You can make a verbal request for an expedited appeal.
5. You do not have to put your expedited appeal request in writing.

When Can You File an Appeal? 

1. When the BHP, Partnership, or the contracted provider determines that you do not meet the access criteria for behavioral health services.
2. Your healthcare provider recommends a behavioral health service for you and requests approval from your BHP or Partnership, but the BHP or Partnership denies the request or alters the type or frequency of service.
3. Your provider requests approval from the BHP or Partnership, but the BHP or Partnership requires more information and does not complete the approval process on time.
4. Your BHP or Partnership does not provide services based on its predetermined timelines.
5. You feel that the BHP or Partnership is not meeting your needs on time.
6. Your grievance, appeal, or expedited appeal was not resolved in time.
7. You and your provider disagree on the necessary behavioral health services.

When Can You File an Expedited Appeal? 

1. If waiting up to 30 days for a standard appeal decision will jeopardize your life, health, or ability to attain, maintain or regain maximum function, you may request an expedited resolution of an appeal. 

Additional Information for Expedited Appeals:

2. If your appeal meets the requirements for an expedited appeal, the BHP or Partnership will resolve it within 72 hours of receiving it.
3. If the BHP or Partnership determines that your appeal does not meet the criteria for an expedited appeal, they are required to provide you with timely verbal notification and will provide you with written notice within two calendar days, explaining the reason for their decision. Your appeal will then follow the standard appeal timeframes outlined earlier in this section.
4. If you disagree with the BHP or Partnership's decision that your appeal does not meet the criteria for expedited appeal, you may file a grievance.
5. After your BHP or Partnership resolves your request for an expedited appeal, you and all affected parties will be notified both orally and in writing.

How Do You Know If Your Appeal Has Been Decided: 

The BHP or Partnership must decide on your appeal within 30 calendar days of receiving your request. 

You or your approved person will receive written notification from your BHP or Partnership of the decision on your appeal. The notification will include the following information:

1. The results of the appeal resolution process.
2. The date the appeal decision was made.
3. If the appeal is not resolved in your favor, the notice will provide information regarding your right to a State Fair Hearing and how to request a State Fair Hearing. Please note: You will have 120 days from the date of the notice of appeal resolution to file for a State Fair Hearing. 

The appeal form can be found in the supporting documents below. 

Shasta County HHSA provides access to personal records using MyHealthPoint, located at https://myhpprovider.netsmartcloud.com/WebPages/Login.aspx. If you are ready to get started, you will need to sign up for MyHealthPoint by contacting your provider. 

For a Step-by-step guide on using the My Health Point Patient Portal 2.0 please review this guide: https://www.shastacounty.gov/media/80686

Part of the Interoperability and Patient Access Rule seeks to establish beneficiaries as the owners of their own health information with the right to direct its transmission to third-party applications. The Patient Access API emerged as a result of this. This API allows beneficiaries to access health information on an application of their choosing. 

Learn how to use the Patient Access API by going to the API documentation here: Payer Patient Access API | Netsmart CareConnect and, Provider Patient Access API | Netsmart CareConnect
Additional documentation for the Patient Access API can be found here: NDE | API Methods (netsmartcloud.com).

To request authorization for third-party application to Shasta County HHSA Patient Access API, please click on this link: Information Sharing - Questionnaire | Netsmart (ntst.com).

Resources for CMS Interoperability and Patient Access Final Rule: 

CSM Final Rule 

Description: Interoperability and Patient Access Final Rule (May 1, 2020) Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability and Patient Access for Medicare Advantage Organization and Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, and Health Care Providers (85 Fed. Reg. 25510)

21st Century Cures Act: 

Cures ACT 

Description: Interoperability, Information Blocking, and the ONC Health IT Certification Program

Provider Directory API
Making well-informed decisions are important. The Provider Directory API enhances beneficiaries' access to care by providing the most accurate and precise in-network provider information.

The Provider Directory API documentation can be found here: Provider APIs | Netsmart CareConnect.

Process for Testing with Postman: Testing FHIR Provider Directory with Postman | Netsmart CareConnect

Resources for CMS Interoperability and Patient Access Final Rule: 

CSM Final Rule 

Description: Interoperability and Patient Access Final Rule (May 1, 2020) Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability and Patient Access for Medicare Advantage Organization and Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, and Health Care Providers (85 Fed. Reg. 25510)

21st Century Cures Act: 

Cures ACT 

Description: Interoperability, Information Blocking, and the ONC Health IT Certification Program

Please note: The Provider Directory API does not require user authentication to use the API. However, Shasta County HHSA does require third-party developers to request for access to the API's data elements. 

To request for access, please click on this link:  Information Sharing - Questionnaire | Netsmart (ntst.com).  Shasta County Survey for Access by Third-Party Apps: https://forms.office.com/g/SG0BDBwSSJ

Once access has been granted, developers will need to follow the "Token Endpoint" authentication method as described here: https://careconnect-dev.netsmartdev.com/docs/certified/authorization/.

How to Register a Third-Party app with our FHIR API

Welcome to Netsmart: Care Connect documentation: Introduction | Netsmart CareConnect

-What is Care Connect?

-Getting Started

-Who Should Use this documentation?

-Documentation Structure

-Standard and Compliance

-Support and Community

Application Registration Steps: Application Registration | Netsmart CareConnect

-Registering your application

-Creating and Account

-Registering Your Application

-Requesting Authorization 

HL7 FHIR Home Technical information for Developers:

https://hl7.org/fhir/

https://hl7.org/fhir/us/carin-bb/

https://hl7.org/fhir/us/davinci-pdex/

https://build.fhir.org/ig/HL7/davinci-pdex-formulary/

Registered Developer Log in Page: Netsmart Developer Console

Click this link to go to the developer's portal: Developer's Portal.

In addition to the API information above- Partnership offers API connection for third party apps at the following website: Partnership Developer Resources

Privacy Practices for Clients

Link to the Privacy Practices and how Client can protect their health information: Privacy Practices Medical Records

How can clients use precautions when using technology for accessing their client information:

Is sharing my healthcare information online safe? 

When making decisions about your health, it is important to share your healthcare information only with people and apps you trust. This includes family, doctors, or others who help take care of you. 

To keep your information safe, it is suggested following the safeguards below: 

-Only use trusted health apps or software to manage your healthcare information. 

-Keep your log-in and password information private. Never share your log-in and password with anyone.

-Store paper records in a secure location, such as in a locked filing cabinet or a safe. 

-Purchase virus protection software for your computer. 

-Avoid sending sensitive information via email unless it is protected with a strong password. 

-To learn more information regarding online security, refer to: 

How Websites and Apps Collect and Use Your Information | Consumer Advice.

Below you will find the resources to file with the Office for Civil Rights (OCR) and the Office for Federal Trade Commission in the event of unfair practices:

Responsibilities of Office for Civil Rights and how to file a complaint with the Office of Civil Rights (OCR)

Responsibility of the Office of Civil Rights: About Us | HHS.gov

How to file a complaint with the Office of Civil Rights (OCR): Filing with OCR | HHS.gov

Responsibilities of Office for Federal Trade Commission and how to file a complaint with the Federal Trade Commission (FTC): What the FTC Does | Federal Trade Commission

How to file a complaint with the Office for federal Trade Commission (FTC):

Report fraud, scams, and bad business practices at ReportFraud.ftc.gov.
Report identity theft at IdentityTheft.gov.
Report unwanted calls at donotcall.gov.

Contact the Consumer Response Center by calling 1-877-FTC-HELP (382-4357)

Below are some guidelines to use when identifying if a group is a HIPAA covered entity or a non-HIPAA covered entity:

HIPAA-covered entities include healthcare providers (doctors, hospitals, pharmacies) that conduct electronic transactions, health plans (insurers, Medicare, HMOs), and healthcare clearinghouses. Also included are Business Associates (vendors handling PHI for covered entities). Non-covered entities generally include employers, life insurers, schools, and many tech/wellness companies. 

Likely HIPAA-Covered Entities 

• Healthcare Providers: Doctors, clinics, psychologists, dentists, chiropractors, and nursing homes that transmit health information electronically in connection with a standard transaction.
• Health Plans: Health insurance companies, HMOs, company health plans, Medicare, Medicaid, and long-term care insurers.
• Healthcare Clearinghouses: Entities that process nonstandard health information into a standard format.
• Business Associates: Third-party administrators, billing companies, and IT vendors that perform services involving Protected Health Information (PHI) for a covered entity. 

Likely Non-Covered Entities 

• Employers: In their role as employers such as for HR records or workplace drug testing.
• Insurance (Other): Life insurers, workers' compensation carriers, and auto insurers.
• Schools & Districts: Records covered by the Family Educational Rights and Privacy Act (FERPA).
• Tech & Services: Many consumer wellness apps, direct-to-consumer genetic testing companies, and wearable device makers (unless acting on behalf of a covered entity).

• State Agencies: Child protective services and law enforcement agencies. 
   

   

Guide for Choosing the Right 3rd Party app and safety guidelines for Clients and Representatives

Third-party applications are tools created by outside developers rather than Shasta County. These apps use Patient Access APIs to give you more ways to view and use your health records beyond the standard medical portal.

Common Examples:

• Health & Fitness Apps: Track medications, find doctors, or sync wearable data.
• Financial Tools: Manage healthcare costs and insurance plans.

When you choose an app, Shasta County securely shares your data with it via an API, acting as a bridge to help you better manage your information.

Using Safe-Guards to protect yourself when choosing a 3rd party app:

When choosing a health-related application (3^rd Party App), it is important to remember that granting permission often gives the software full access to your sensitive medical information. Because most third-party apps are governed by the Federal Trade Commission (FTC) rather than HIPAA laws, you must take proactive steps to protect your privacy.

Key Steps Before You Download

• Investigate the Developer: Prioritize apps with a solid track record for security and data protection.
• Verify Compliance: Look for specific certifications, such as HIPAA compliance, which signal that the app meets higher security benchmarks.
• Analyze Privacy Notices: Legally, an app must follow the rules it publishes. Carefully read these policies to see how they intend to use, store, and safeguard your personal details.

Questions to Consider

If an app’s privacy policy doesn't clearly answer the following questions, you may want to reconsider using it:

• Data Collection: What specific health or device information (like your GPS location) is being gathered?
• Anonymization: Is your data stored in a way that removes your personal identity?
• Third-Party Sharing: Will your information be sold to advertisers or shared with researchers? If so, for what purpose?
• User Control: Can you limit how the app uses your info or correct inaccuracies in your records?
• Security & Complaints: What specific measures protect your data, and how does the company handle user grievances?
• Account Deletion: If you stop using the app, how do you revoke access and ensure your data is permanently deleted? (Note that simply deleting the app from your phone may not be enough).

Understanding the Legal Landscape

It is a common misconception that all health apps are protected by HIPAA (the Health Insurance Portability and Accountability Act). In reality, HIPAA generally only applies to information shared for medical treatment or insurance purposes.

Most consumer apps fall under the FTC Act, which protects you against deceptive practices. This means if an app shares your data despite a privacy policy claiming it won't, the FTC can take legal action. For more details on staying safe, you can visit the FTC’s guide on understanding mobile apps.