Grievances and Appeals

 Participant Grievance Process

What is a Grievance?

  • A grievance is defined as a complaint, either written or oral, expressing dissatisfaction with the services provided or the quality of your care that is provided by PACE of Southwest Michigan.

  • You have the right to file a grievance about anything.  Examples are:

  • The quality of services you receive in the home, at the PACE of Southwest Michigan PACE Center, or in any inpatient or housing facility (hospital, nursing home, or assisted living facility). 

  • Mistakes you feel have been made by PACE of Southwest Michigan.

  • Waiting times on the phone or in the waiting/exam room.

  • Behavior of any of your care providers or program staff.

  • Adequacy of PACE of Southwest Michigan PACE Center facilities.

  • Quality of food provided by PACE of Southwest Michigan; and

  • Transportation provided by PACE of Southwest Michigan.


  • You may file a grievance with any PACE of Southwest Michigan staff member at any time, either verbally or in writing. 

  • During the grievance, process we will continue to furnish you with PACE services at the frequency provided in your current plan of care. Your grievance will be kept confidential by all PACE of Southwest Michigan staff.

 

Participant Appeal Process

What is an Appeal?

If PACE of Southwest Michigan refuses to provide or pay for a service that you feel is necessary for your health, you or your representative have the right to request an appeal of PACE of Southwest Michigan’s decision.  If your Personal Care Team denies a request for services or payment or reduces your services, your team will provide you written information about the denial and about how to file an appeal.

You may request an appeal if PACE of Southwest Michigan:

  • Denies a Service: refuses to provide a service you have requested 

  • Reduces a Service: reduces a previously approved service you are presently receiving

  • Denies Payment for a Service: refuses to pay for a service you have already received

  • Does Not Act Promptly: fails to respond in the required time to a request for services or payment

  • Disenrolls you on an involuntary basis 

  • Refuses to enroll you in the program

There are two types of appeal systems available to you:

1.    The PACE of Southwest Michigan Internal Appeal process

2.    The external Medicare or Medicaid Appeals process


ALL APPEALS ARE KEPT CONFIDENTIAL

When an appeal is filed, PACE of Southwest Michigan staff will keep the matter private and only involve those persons directly responsible for resolving the appeal.


Internal Appeal Process with PACE of Southwest Michigan

How to File an Internal Appeal 

If PACE of Southwest Michigan denies a request for a service or payment for a service, you have the right to file an internal appeal either verbally or in writing to PACE of Southwest Michigan.  You may request this type of an appeal within 30 calendar days of the day PACE of Southwest Michigan notifies you that your request for service(s) has been discontinued, reduced, or denied. A person not involved in the Personal Care Teams initial decision to discontinue, reduce, or deny any service(s) in question will evaluate the appeal.  You or your authorized representative may present or submit relevant facts and/or evidence for review to PACE of Southwest Michigan. 

Until you receive notice of a final decision, you may choose to continue to receive any service(s) in question.  You may have to pay for these services if the final decision is not in your favor.  You also have a right to file an appeal with the State of Michigan at the same time you have filed an appeal with PACE of Southwest Michigan.

PACE of Southwest Michigan will decide on the appeal as promptly as your health condition requires but no later than thirty (30) calendar days after receiving the request for an appeal.

Requesting an Expedited Appeal

If you feel a discontinued, reduced, or denied service is urgently needed in order to avoid serious harm to your health, you may request an expedited appeal.  You may submit the appeal yourself or ask for assistance from any member of your Personal Care Team. 

By requesting this type of appeal, PACE of Southwest Michigan will automatically expedite its review of your appeal.  PACE of Southwest Michigan must give you a decision on your appeal as quickly as your health condition requires but no later than 72 hours after your request for an expedited appeal.

Extending the Expedited Review Time Period

The 72-hour timeframe in an expedited appeals review may be extended up to 14 calendar days for either of the following reasons:

1)    if you or your caregiver requests the extension, or

2)    if PACE of Southwest Michigan justifies to the State of Michigan the need for additional information and the delay is in your interest. 

External Appeal Process with Medicare and/or Medicaid

If PACE of Southwest Michigan discontinues, reduces, or denies your request for a service or payment of a service, you may choose to file an external appeal.  The external appeals process provides a review through either the Medicare or Medicaid program.  Until you receive notice of a final decision, you may choose to continue to receive the service(s) in question.  PLEASE NOTE: You may have to pay for these services if the final decision is NOT in your favor.

You may choose to file an external appeal to either Medicare or Medicaid (but not both) depending on your eligibility.  Please talk with a Personal Care Team member or call PACE of Southwest Michigan at 269-408-4322 or 1-855-243-8876, if you would like help in filing an external appeal.  PACE of Southwest Michigan will assist you in choosing either the Medicare or Medicaid external appeal process and will forward information accordingly.

 

MEDICAID EXTERNAL APPEALS PROCESS

If you are eligible for Medicaid, you may choose to use the Medicaid external appeal process.  Even if you begin with the PACE of Southwest Michigan appeal process, you have the right at any time to go directly to the State of Michigan.

For assistance in completing this process, you may contact any of the following resources:

  • PACE of Southwest Michigan: PACE of Southwest Michigan can help you complete this process.  You may request help from any PACE of Southwest Michigan staff member or you may contact PACE of Southwest Michigan directly at:

    PACE of Southwest Michigan

    2900 Lakeview Avenue

    St. Joseph, MI 49085

    269-408-4322 or 1-855-243-8876


  • State of Michigan: You may contact the State of Michigan and request an external appeal within ninety (90) days of PACE of Southwest Michigan’s decision.  To request an external appeal, please contact the State of Michigan in writing at:

    State Office of Administrative Hearings and Rules

    Department of Community Health

    Administrative Tribunal

    PO Box 30763

    Lansing, Michigan 48909

    (877) 833-0870


Important Note

PACE of Southwest Michigan will continue to provide the service(s) in question until a final decision on the appeal has been made.  You might have to pay for the services if the appeal decision is not in your favor.  PACE of Southwest Michigan or its provider can bill you for the costs of the appealed services, but only if you signed a form in advance saying that you understand you may have to pay for the services. PACE of Southwest Michigan will continue to provide you with all of the other services that have been authorized by your Personal Care Team.

What is the Medicare External Appeals Process?

If you are eligible for Medicare and wish to use the Medicare appeal process, you must go through the PACE of Southwest Michigan appeal process before your appeal can go to an outside appeals organization.

Medicare contracts with an independent review entity to review appeals for PACE programs like PACE of Southwest Michigan.  The independent review entity will contact PACE of Southwest Michigan with the results of their review.

If you would like to designate a representative to assist you with an appeal, please go to: https://www.hhs.gov/about/agencies/omha/filing-an-appeal/your-right-to-representation/index.html