Grievance and Appeal Process

It is the policy of Franciscan PACE to assure that all participants, participant’s family members, designated representative, and/or caregiver understand the established grievance process should a concern/complaint about their care arise. A written record of all grievances shall be maintained, including the initial date, identification of the grievance, and the date of resolution, along with the resolution. All grievances will be reviewed on a routine basis by the Senior Director and Leadership Team.

The Quality Manager/Quality Outcomes Analyst will maintain this information in order to foster an environment of continuous improvement. Grievance information will be made available for review by CMS and/or the State Department of Health upon request. There shall be no discrimination against a Participant on the grounds that he/she has filed a grievance. In order to maintain confidentiality in the grievance process, all staff members will review the Confidentiality Policy as part of their annual education.

Definition: A grievance is defined as a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished, regardless of whether remedial action is requested. Grievances may be between participants and Franciscan PACE or any other entity or individual through which Franciscan PACE provides services to the participant.

Grievance Process Notification to Participants: Upon enrollment, and at least annually thereafter, Franciscan PACE will give the participant written information on the grievance process in understandable language, including all of the following:

1. A participant or other individual as defined below, has the right to voice grievances without discrimination or reprisal, and without fear of discrimination or reprisal.
2. A Medicare participant or other individual as defined below acting on behalf of the Medicare participant has the right to file a written complaint with the Quality Improvement Organization (QIO) with regard to Medicare covered services.
3. The requirements under 42 CFR §460.120(b), and §460.120(d)-(j).

Who Can Submit a Grievance:

1. Participant
2. Participant’s family member
3. Participant’s designated representative
4. Participant’s caregiver

A grievance may be expressed orally or in writing to any staff member or contractor of Franciscan PACE that provides care to the participant in the participant’s residence, the PACE center, or while transporting participants at any time. The staff member will inform the Center Manager or their designee. The receptionist shall forward any incoming grievances via telephone to the appropriate center staff or the Center Manager.

Franciscan PACE Baton Rouge
7436 Bishop Ott Drive, Baton Rouge LA
Phone: (225) 490-0604
Fax: (225) 490-0354

Franciscan PACE Lafayette
501 W. St. Mary Blvd., Suite 200, Lafayette LA
Phone: (337) 470-4500
Fax: (337) 470-4515

If, during non-center operational hours, the participant, participant’s family members, designated representative, and/or caregiver wishes to make a grievance, Administration On-Call will be responsible for receiving and then communicating the grievance to the Center Manager or designee the next business day.

1. A Grievance Log will be maintained at each facility. Every grievance will be documented within 72 hours from when it is received. If a grievance was received after hours, it will be documented in the on-call log as well as the Center Grievance Log the next business day or within the 72 hours.
2. It is the responsibility of the Center Manager or designee receiving the grievance to ensure documentation is complete.

1. Franciscan PACE will conduct a thorough investigation of all distinct issues within the grievance when the cause of the issue is not already known.
2. Franciscan PACE must take action to resolve the grievance based on the results of its investigation as expeditiously as the case requires, but no later than 30 calendar days after the oral or written grievance is received.
3. Franciscan PACE will continue to provide all required care to the participant throughout the grievance process.
4. Franciscan PACE will maintain the confidentiality of a grievance, including protecting the identity of all individuals involved in the grievance from other employees and contractors when appropriate.

1. The Center Manager or designee involved, along with the IDT when appropriate, will investigate and seek a favorable resolution of the grievance, depending on the nature and circumstance of the grievance.
2. The grievance and resolution will be discussed by the necessary team members who will be involved in the resolution of the grievance, while continuing to adhere to confidentiality requirements. The participant, participant’s family members, designated representative, and/or caregiver will receive notification from Franciscan PACE of the grievance resolution as expeditiously as the case requires, but no later than 3 calendar days after the date Franciscan PACE resolves the grievance. The individual who submitted the grievance will be notified either orally and/or in writing of the resolution based on the individual’s preference for notification. At a minimum, the grievance resolution will include:
   • summary statement of the participant’s grievance including all distinct issues.
   • summary of the pertinent findings or conclusions regarding the concerns for each distinct issue that requires investigation.
   • for a grievance that requires corrective action, the corrective action(s) taken or to be taken by Franciscan PACE as a result of the grievance , and when the participant may expect corrective action(s) to occur.
3. All grievances related to quality of care, regardless of how the grievance is filed, must be responded to in writing.
   • The response must describe the right of a Medicare participant or other individual as outlined in the section, “Who Can Submit a Grievance” acting on behalf of a Medicare participant to file a written complain with the QIO (Quality Improvement Organization) with regard to Medicare covered services.
   • For any complaint submitted to the QIO, Franciscan PACE must cooperate with the QIO in resolving the complaint.
4. Franciscan PACE may withhold notification of the grievance resolution if the individual who submitted the grievance specifically requests not to receive the notification, and Franciscan PACE has documented this request in writing. Franciscan PACE is still responsible for complying with all other requirements as outlined.

1. Any participant, participant’s family members, designated representative, or caregiver who is dissatisfied with the outcome of the grievance resolution proposed by the team can take further action. He/she may contact the Senior Director within 30 calendar days of the team’s resolution notification.
2. All efforts will be made by the Senior Director to resolve the ongoing grievance with the resources of the program, to include the Ethics Committee, as well as the Quality Committee.
3. If the participant, participant’s family members, designated representative, and/or caregiver is still not satisfied with the resolution proposed, he/she can request a review by the Program Director. The Program Director may at any time draw upon these same resources in responding to the initial grievance.

Franciscan PACE will track and maintain records related to all processing requirements for grievances received both orally and in writing. These records, except for information deemed confidential as outlined in the section titled: “Investigation of a Grievance”, will be available to the IDT to ensure all members remain alert to pertinent participant information.

1. Franciscan PACE will aggregate and analyze the information collected in the records for purposes of its internal quality improvement program.
2. Trends and patterns will be identified by the Quality Manager/Quality Outcomes Analyst and reported to the Leadership Team. In addition, identified trends and patterns will be reported back to the Interdisciplinary Team involved, who in turn, will develop an action plan for resolving the negative trend.
3. The center will forward reports to the Quality Manager/Quality Outcomes Analyst, who is responsible for maintaining, aggregating, and analyzing information on grievance proceedings. By analyzing the number and types of grievances, Franciscan PACE can develop activities that will monitor and improve the grievance resolution process, as well as identify and make improvements or modifications in areas of care.

The grievance process will be reviewed annually with participants, participant’s family members, designated representative, or caregiver contract providers and all employees.

It is the policy of Franciscan PACE (herein referred to as PACE) to provide and coordinate all PACE covered services determined necessary by the Interdisciplinary Team (IDT) to meet the needs of the Participant. An appeal is defined as the Participant’s and/or designated representative’s action with respect to PACE’s non-coverage of, or non-payment of, a service, as well as PACE’s request for an involuntary disenrollment. A request to initiate, modify or continue a service must first be processed as a service determination request before PACE can process an appeal.

All requests for appeals will be treated in a confidential manner. Any violations of confidentiality by PACE employees will result in disciplinary action. To maintain confidentiality, all PACE staff members will review the Confidentiality Policy as part of their orientation and annual in-service requirements. Contracted providers will be held accountable to all appeal procedures established by PACE as outlined in the Franciscan PACE’s Provider Manual. PACE will monitor contract providers’ compliance with this requirement on an annual basis.

If, during non-Center operation hours, the Participant and/or designated representative wishes to file an appeal, the on-call staff member will be responsible for receiving and then communicating the appeal to the Center Manager (or designee) the next business day.

1. Upon enrollment, and at least annually thereafter, and whenever the IDT denies a request for services or payment, Franciscan PACE will give the Participant written information on the appeals process. Participant notification will include the availability of assistance with completing an appeal.
2. All requests to appeal a decision must be made within 14 calendar days of receipt of denial notification and will be documented in an appeal log and maintained in a confidential location. Requests for appeals will be documented by the staff member who receives the request. All expedited requests will be brought to the immediate attention of the Center Manager (or designee).
3. The service in question will be reviewed for appropriateness taking into consideration the medical, physical, emotional, and social needs of the Participant. Additional information may be needed to adequately evaluate the appeal.
4. All parties involved in the appeal will have the opportunity to present evidence both in person and in writing as it relates to the appeal.

1. An appeal must be expedited if there is belief the Participant’s life, health, or ability to regain or maintain maximum function would be seriously jeopardized without the services in question being provided. If the Participant does not request an expedited review, the Center Manager (or designee) will determine if the appeal requires an expedited review process. In the case of expedited requests, the Center Manager (or designee) will immediately contact the necessary IDT for discussion and review of the recent assessment or request.
2. Franciscan PACE will respond to an appeal as expeditiously as the Participant’s health condition requires, but no later than 72 hours after it receives the appeal.
3. Franciscan PACE may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons:
   • The Participant requests the extension.
   • Franciscan PACE justifies to Louisiana Department of Health (LDH) the need for additional information and how the delay is in the interest of the Participant.

1. During the appeals process, Franciscan PACE will meet the following requirements:
   • For a Medicaid Participant, continue to furnish the disputed services until issuance of the final determination if the following conditions are met:
     • Franciscan PACE proposes to terminate or reduce services currently being furnished to the Participant.
     • The Participant requests continuation with the understanding that he/she may be liable for the costs of the contested services if the determination is not made in his/her favor.
   • Continue to furnish to the Participant all other required services during the appeals process. There shall be no discrimination against a Participant on the grounds that he/she has filed an appeal.

1. If an appeal is not expedited and is being reviewed by a Third-Party Reviewer or committee, Franciscan PACE must respond to and resolve the appeal as expeditiously as the Participant’s health condition requires, but no later than 30 calendar days after receiving the appeal.
2. An appropriate Third-Party Reviewer or committee will be an individual(s) who meet all of the following:
   • Appropriately credentialed in the field(s) or discipline(s) related to the appeal.
   • An impartial third-party who meets both of the following:
     • Is not involved in the original action.
     • Does not have a stake in the outcome of the appeal.
3. For Franciscan PACE, a Third-Party Reviewer or committee may include but is not limited to:
   • Franciscan PACE’s sister/opposite site. This is the designated objective Third-Party Reviewer for PACE. The PACE Baton Rouge IDT will review the PACE Lafayette IDT denials, and the PACE Lafayette IDT will review the PACE Baton Rouge IDT denials.
   • Designated review committee.
   • Medical Advisory Board Members
   • Other community physicians
4. If an appeal is being reviewed by a Third-Party Reviewer or committee, documentation will be provided either in writing or submitted electronically to the Third-Party Reviewer or committee. This information will, at a minimum, explain:
   • Services must be provided in a manner consistent with the requirements in 42 CFR § 460.92 and 42 CFR § 460.98.
   • The need to make decisions in a manner consistent with how determinations under the Social Security Act section 1862(a)(1)(A) are made.
   • The rules in 42 CFR § 460.90(a) specify certain limitations and conditions applicable to Medicare or Medicaid or both benefits do not apply.

1. Franciscan PACE will give all parties involved in the appeal appropriate written notification of the decision to approve or deny the appeal.
2. For a determination in favor of a Participant, Franciscan PACE will furnish the disputed service as expeditiously as the Participant’s health condition requires. Franciscan PACE must explain the conditions of the approval in understandable language.
3. Any determinations that are adverse to the Participant either wholly or in part, will require notification to the Centers for Medicare and Medicaid (CMS) and the Louisiana Department of Health.
4. For any determination adverse to the Participant either wholly or in part, Franciscan PACE will inform a Participant in writing of his or her appeal rights under Medicare or Medicaid managed care, or both, assist the Participant in choosing which to pursue if both are applicable, and will forward the appeal to the appropriate external entity. The notice of denial must:
   • state the specific reason(s) for the denial.
   • explain the reason(s) why the service would not improve or maintain the Participant’s overall health status.
   • inform the Participant of his/her right to appeal the decision.
   • describe the external appeal rights under 42 CFR § 460.124.

Franciscan PACE will maintain, aggregate, and analyze information on appeal proceedings and use the information when developing the Quality Improvement (QI) program. A written record of all appeals will be maintained, including the initial date of the appeal, identification of the appeal, the date of resolution, and a written description of the resolution. All appeals will be reviewed at least quarterly by the Quality Committee.

1. The Quality Manager (or designee) will maintain, aggregate, and analyze this information to foster an environment of continuous quality improvement. In addition, appeal information will be made available for review by the Louisiana Department of Health (LDH), and/or other authorized representatives upon request.
2. Trends and patterns will be identified by the Quality Manager (or designee) and reported to the Quality Committee and the Management Team on a quarterly basis. In addition, identified trends and patterns will be reported quarterly to the IDT. This information will be incorporated as a formal part of the Quality Plan and the Quality Committee who recommends an action plan for resolving the negative trend.
3. All progress of the Center’s activities towards resolution of a trend in appeals will be monitored by the Quality Committee and/or Management Team.

A Participant will be informed in writing of his/her appeal rights under Medicare or Medicaid managed care, or both. An IDT member will assist the Participant in choosing which to pursue if both are applicable and will forward the appeal to the appropriate external entity.

1. Appeal rights under Medicare.
   • Medicare Participants have the right to a reconsideration by an independent review entity.
   • A written request for consideration must be filed with the independent review entity within 60 calendar days from the date of the decision by the Third-Party Reviewer under 42 CFR § 460.122.
   • The independent review entity must conduct the review as expeditiously as the Participant’s health condition requires but must not exceed the deadlines specified in the contract.
   • If the independent review entity conducts a reconsideration, the parties to the reconsideration are the same parties described in 42 CFR § 460.122(c)(2) with the addition of the PACE organization.
2. Appeal rights under Medicaid.
   Medicaid Participants have the right to a State Fair Hearing as described in 42 CFR § Part 431 Subpart E.
   • State Fair Hearing requests must be filed within 30 calendar days from the date of the decision by the third-party reviewer on the internal appeal.
   • If the participant files their external appeal within 10 calendar days of the date of the decision notice, they may opt to continue to receive the disputed service during the State Fair Hearing process with the understanding that, if the original decision by Franciscan PACE is upheld, they may be required to reimburse Franciscan PACE for the cost of provision of the disputed service during the appeal process.
   • Medicaid appeals are filed with the Louisiana Division of Administrative Law by mail, phone, fax or online:
     
     Division of Administrative Law
     Health and Hospital Section
     P.O. Box 4189, Baton Rouge, LA  70821
     Telephone Number:  (225) 342-5800  
     Fax Number:  (225) 219-9823
     Online: http://laserfiche.adminlaw.state.la.us/Forms/hSgLX
3.  Appeal rights for dual eligible Participants.

Participants who are eligible for both Medicare and Medicaid have the right to external review by means of either the independent review entity described in paragraph (1.) of this section, or the State Fair Hearing process described in paragraph (2.) of this section.