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Grievances & Appeals

Participant Feedback (Grievances)

 

Rocky Mountain PACE shares responsibility for assuring that our participants are satisfied with the care they receive. We encourage our participants to express any feedback (grievances) at the time and place that any dissatisfaction occurs. If a participant does not speak English, please let us know, and an interpreter will be appointed to facilitate the grievance/feedback process.  During the participant’s annual re-assessment, we will also review the Feedback and Appeals process and notify the participant of any changes that may have occurred.

 

A feedback, also known as a grievance, is a complaint, either written or oral, expressing participant dissatisfaction with service delivery or the quality of care furnished. The process to resolve a grievance is as follows:

 

Feedback Process

  • The participant and/or his/her caregiver may either write or discuss feedback with any staff member at Rocky Mountain PACE or a member in the Quality and Compliance Department.
  • Feedback forms are located with the secured Feedback boxes in the lobby and the Day Center. Or they can be handed to any staff member who will deliver to the Quality and Compliance department.
  • The feedback will be logged and followed by the Quality and Compliance Department at Rocky Mountain Health Care Services.
  • The Quality and Compliance staff will determine which staff should be involved to resolve the feedback. The person assigned to determine the feedback resolution will contact the participant and/or caregiver regarding their feedback and solicit suggestions or ideas toward resolving the problem or issue to consider.
  • We make every attempt to reach the participant/caregiver by phone to discuss the proposed resolution.  All participants/caregivers will receive a letter of resolution outlining regardless of whether we were able to reach them by phone. Our policy outlines that we must contact the participant and/or caregiver with the proposed resolution within 30 days; however, our goal is to resolve any feedback much sooner.
  • If the participant and/or caregiver is unhappy with the resolution, they may contact the Quality and Compliance Department of Rocky Mountain Health Care Services at 719.314.2327/ TTY 800.659.2656, Ext. 393 to learn more about next steps which includes the appeal process.
  • During the feedback/grievance process, Rocky Mountain PACE will continue to furnish the participant with all required services as included in their Plan of Care.

 

Rocky Mountain Health Care Services

Attn: Quality & Compliance Department

310 S. 14th Street

Colorado Springs, CO  80904

Phone: (719) 314-2327 Ext. 393

TTY 800-659-2656 Ext. 393

Fax: (719) 314-0077

 

Anonymous Feedback Reporting:

 

If the participant and/or his/her caretaker prefers to contact Rocky Mountain PACE anonymously, separate from filing a feedback or grievance, they may call Rocky Mountain PACE’s compliance hotline number at 855-252-7601 or submit a report through https://www.complianceresource.com/hotline/ enter Rocky Mountain Health Care Services to start the reporting process.

Standard Appeals Process:
All of the staff at Rocky Mountain PACE share responsibility with you, your family or caregiver in providing you the comprehensive health care services identified in your Plan of Care as authorized by the Interdisciplinary Team. You, your family or caregiver are encouraged to contact a member of the Interdisciplinary Team when you have a disagreement with Rocky Mountain PACE’s non-coverage, reduction in services, or of nonpayment for a service.

If we deny your request for a service or for payment of a claim, we will give you a written copy of this information on the appeals process, including a form that you may use to request your appeal. You may also make your appeal known verbally, and PACE staff will document and submit your request for an appeal.

The Rocky Mountain PACE Quality Assurance Manager or designee will respond to you in writing within two working days, stating that your appeal has been received.

A person not involved in our initial decision to deny your request for a service or to pay a claim will reevaluate your appeal. The reviewer will be an appropriately credentialed and impartial individual who was not involved in the original action and does not have a stake in the outcome of the appeal.

You or your authorized representative may present or submit to us relevant facts and/or evidence for review, either in person or in writing for consideration during the appeal process.

Within thirty (30) calendar days of receiving the appeal, Rocky Mountain PACE will notify you by certified mail of the appeals decision. A copy of the notification will be kept in your file.

Rocky Mountain PACE may not stop or reduce services while your appeal is pending. If the appeal is not resolved in your favor, you may be charged for the cost of the services.

 

Click here to download and complete the Request to Appeal Form.

Your Right to Representation

To appoint a representative, you or your representative should complete the form entitled:  Appointment of Representative -CMS-1696 – PDF.  If you do not use form CMS-1696, your appointment must:

  • Be in writing and signed and dated by you and your representative;
  • Provide a statement appointing the representative to act on your behalf;
  • Authorize the release of your personal health information to your representative;
  • Include a written explanation of the purpose and scope of the representation;
  • List your name and your representative’s names, phone numbers, and addresses;
  • Include your Medicare Number (Health Insurance Claim Number or Medicare Beneficiary Identifier) or National Provider Identifier (NPI);
  • Indicate your representative’s professional status, if any, or relationship to you; and
  • Be filed with the entity processing your appeal.

Unless revoked, an appointment is considered valid for one year from the date the form is signed. Once the form is filed, it is valid for the duration of the appeal. Therefore, a signed form can be used for more than one appeal as long as the appeal is filed within one year of the date on the form.

In addition, there are certain individuals who can bring an appeal on your behalf, pursuant to State or other applicable laws.  Such an individual, known as an “authorized representative,” may be a court-appointed guardian, an individual who has durable power of attorney, a health care proxy, or a person designated under a State’s health care consent statute.

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