J-8_Grievance_Overview.docx

Grievance Overview for 2016-20 SOW Networks shall conduct case review based on contacts from patients, facilities and other sources. The Grievance procedures are currently being updated and will be available prior to the start of the 2016-20 SOW. Below is a brief overview of the revised requirements for the grievance processes:

1. All contact information will be entered into the Patient Contact Utility (PCU). A separate location in the PCU will be available for non-Grievance/Access-to-Care contacts.

2. All patient contacts will be queried per their willingness to participate in the CMS Patient Grievance survey. Networks will provide monthly updates of these patients to the National Coordinating Center (NCC).

3. Cases from person other than patient (but not facility) requires at least documentation of appointed representative status; Network sends letter and attempts to get written documentation (use appointed representative template #1).

4. For all cases the Network determines the level of confidentiality required. Any case may be anonymous, confidential or open-sharing of the patient’s name. If the Network cannot process the case based on the level of sharing that the grievant is willing to do, the Network will inform the grievant they cannot continue unless they are willing to come to the level necessary. If the grievant is unwilling to escalate their sharing level, the Network will close the case.

5. If the circumstances of the case escalate the Network will process the case at the higher level and meet all requirements for that type of case.

4. Grievances are one of five “types”, as shown below. Cases may include multiple issues, so long as they all meet the type criteria. Networks may have different types of grievances being processed simultaneously for a single grievant. Case types are:

i. No Facility/practitioner letter review; may contact Network for corrections;

ii. If contacted, Network determines if revised letter needs to be sent out

h. There are no re-reviews

i. Patient may request that case be re-opened if new information is provided

ii. Patient may contact CMS Regional Office (RO)/State Survey Agency (SSA)

iii. CMS RO will check for Network Case Review processes

a. Not all will need referral to SSA

b. If referred to SSA, notify the Contracting Officer’s Representative (COR) immediately (same day as SSA)

5. Network determines if case needs to be referred to Medical Review Board (MRB)

a. Not all cases will need MRB, if RN (with Nephrology exp.) can handle

b. Cases to MRB are for Physician review;

G. Non Grievance/Access to care contacts

1. Networks will provide sufficient information to document the contact H. Linkages

1. Linkages between cases will be made between contacts in the PCU as appropriate. Cases may be linked between multiple cases. This is especially true when Non-Grievance/Access to care contacts escalate into grievances/Access-to-care contacts