Complaints, Grievances, & Clinical Appeals

Expectations of Providers

First-Level Complaints

In compliance with Pennsylvania Act 68, Community Behavioral Health (CBH) is required to investigate and respond to all complaints brought to its attention by CBH members or, in the case of children, by parents/guardians. CBH requests a written response from provider agencies in pursuit of a resolution to such complaints. The expectation is that the provider will send the written response to CBH within seven (7) days. If a member or legal guardian requests a copy of any correspondence received from the provider related to the complaint response, CBH is required to forward it to them. Provider cooperation is essential and is documented in every complaint.

Second-Level Complaints

CBH is compelled by Pennsylvania Act 68 to hold hearings for all second-level complaints and grievances upon request by CBH members; the scheduling and execution of these hearings often requires a great investment of time for CBH, the provider, and our members. It is our expectation that providers will participate in second-level complaint/grievance hearings and will be prepared to address the questions and concerns of both the hearing panel and the CBH member(s) involved.

Clinical Appeals

CBH will accept clinical appeals within ninety (90) days of the member’s discharge from treatment. The provider is required to submit a cover letter that includes the Dates of Service, Level of Care, and Rationale for the clinical appeal. If CBH is not the primary payer, the provider is required to indicate what days the primary payer paid.

For details regarding the complaint, grievance, and clinical appeal processes, see the “Quality Management” section in the Provider Manual.