Appeals and Grievances
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Appeals – Call the Recipient Rights/Customer Services Department – 989-928-3566 – for help
You can ask for an appeal if Recovery Pathways, LLC or one of its contracted providers have made a decision about your treatment services and you disagree with the decision. Such decisions include: ending, reducing or suspending your services as well as denying your access to services or delaying authorization decisions. Anytime you disagree with a decision, you can file an appeal by contacting Recovery Pathways, LLC at 989-928-3566.
If you have Medicaid or Healthy Michigan Plan (HMP), you have 60 calendar days to file an appeal from the date of a Notice letter. Treatment providers mail Notice letters to individuals when the provider makes a decision to deny, suspend, reduce or end treatment services, as well as delays an authorization decision. This letter is called a “Notice of Adverse Benefit Determination”.
Once you file a standard appeal, we have 30 calendar days to complete it. You can also ask for an expedited, or quick, appeal if waiting 30 calendar days for a decision could cause you serious harm. A quick appeal will give you an answer within 72 hours. If you are not informed of a decision within 30 calendar days for a standard appeal or 72 hours for a quick appeal, you can file for a Medicaid State Fair Hearing.
If you have Medicaid or HMP and the Notice letter indicates that a service will be reduced, suspended, or terminated in the future, you can request continuation of that service while the appeal is being completed. You must request such by contacting Recovery Pathways, LLC Recipient Rights/Customer Service at 989-928-3566 no later than the effective date of the adverse action, which is in the Notice letter.
If you do not have Medicaid or HMP, you have 30 calendar days from the date of a Notice letter to file an appeal. We then have 45 calendar days to complete the appeal. Those without Medicaid can also ask for a quick appeal, but only in certain situations, such as being denied inpatient psychiatric hospitalization. For those who do not have Medicaid or HMP, our department must complete a quick appeal within 3 business days.
During the appeal process, you can ask to see what information was used to make the decision. You can give us any information you think would help in making the best decision about your services.
You can also ask for a second opinion if you are denied services.
You can file a grievance, or formal complaint, about any concern, question or complaint you may have about your mental health or substance use disorder treatment services provided by Recovery Pathways, LLC or a Recovery Pathways, LLC contracted provider. This includes services you receive now or have received in the past. You can file a grievance at any time about anything. Someone else, such as a provider, can file a grievance for you if they have written consent to do so.
To file a grievance, please call the Recipient Rights/Customer Service Department at 989-928-3566 or fill out the Grievance Request Form and mail it to our CS Department at the address on the form. Once a grievance is filed, our office has 90 calendar days to complete it for those who have Medicaid or Healthy Michigan plan (HMP). If you do not have Medicaid or HMP, we have 60 calendar days to complete it.
State Fair Hearings
A Medicaid State Fair Hearing is a type of hearing that is performed by a state-level administrative law judge. You can ask for this hearing if you do not like the outcome of the appeal you filed with our department. The staff of the Recovery Pathways, LLC Recipient Rights/Customer Service office can help you file for a Fair Hearing. Please call us at 989-928-3566 if you want help.
You must ask for this hearing in writing and it must be signed by you or your legal guardian. The request needs to be mailed to the Michigan Office of Administrative Hearings and Rules (MOAHR) within 120 calendar days of the date the appeal disposition letter was sent to you. An appeal disposition letter informs you of the final decision of the local appeal. A request written by you or a completed “Request for State Fair Hearing” form should be mailed to:
MICHIGAN OFFICE OF ADMINISTRATIVE HEARINGS AND RULES
FOR THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 30763
LANSING, MI 48909
You can click on the link below for a copy of the Request for State Fair Hearing form:
Grievance Appeals Brochure
You can click on the link below for more information on Medicaid Fair Hearings: Rights and Responsibilities:
You can also call Recovery Pathways, LLC Customer Service at 989-928-3566 to request a State Fair Hearing Request form or to ask for help in completing the form.
Please note that you may choose to have another person stand in for you or take part in the hearing. This person can be anyone you choose, including a service provider and/or an attorney. This person may request a hearing for you. You may have to give this person written permission to represent you. You have many options.
If you need an answer right away and feel your situation could become worse by waiting, you can request a quick hearing by calling: 989-928-3566.
If you request a hearing before services are scheduled to be changed, your services may continue until a judge makes a decision about your case. To continue services, you must contact Customer Service within 10 calendar days of the mailing date of the Notice of Adverse Benefit Determination. This is the letter sent to you to tell you about the decision to deny, suspend, terminate or reduce your services. If the judge does not rule in your favor, you may be asked to pay for the services you used, up to your ability to pay.
Michigan Department of Health and Human Services (MDHHS) Alternative Dispute Resolution
This dispute process is available to people without Medicaid or HMP who disagree with the outcome of their local appeal. If you do not agree with an appeal decision made by Recovery Pathways, LLC, you have 10 days from the mailing date of the appeal disposition letter, to file for an MDHHS Alternative Dispute Resolution.
You may contact the Recipient Rights/Customer Service Department at 989-928-3566 for help filing for this process, or you may send a written request to:
Michigan Department of Health and Human Services
Division of Program Development, Consultation and Contracts
Bureau of Community Mental Health Services
ATTN: Request for MDHHS- Level Dispute Resolution
Lewis Cass Building – 5th Floor
Lansing, MI 48913