Provider Dispute Resolution Procedure

Section: Case Management Agency (CMA)
Created: 02/25/2024
Revised:
Effective: 03/01/2024

Policy

It is Weld County CMA's (WCCMA) policy to ensure the fair and equitable resolution of disputes between Members or Individuals and Provider Agencies, in accordance with Section 25.5-10-212, C.R.S. and 10 CCR 2505-10 Section 8.7202.S. WCCMA shall utilize clear procedures for addressing disagreements related to ineligibility for services and supports, termination, or modifications of services and supports as outlined in Person-Centered Support Plans.

Scope

This policy applies to Members and families who are in dispute with a Provider Agency regarding services under a State General Fund Program (State SLS, OBRA-SS). It covers the following situations:

• Member ineligibility for services or support.
• Termination, reduction, or denial of services or supports.
• Changes to the Person-Centered Support Plan without consent.

Contract Section(s)

4.1.4 State General Fund Program Obligations: Contractor shall have procedures for a dispute resolution process, as described in 10 C.C.R. 2505-10, Section 8.605.2 et seq. and 8.552.9 et seq., when an action to terminate, change, reduce or deny services is initiated by the provider service agency.

Relevant Rule(s)

10 CCR 2505-10 Section 8.7202.S

Colorado Revised Statute

C.R.S 25.5-10-212

Steps for Dispute Resolution

1. Notification of Dispute Process
   • Procedure: WCCMA will inform Members, applicants, and their representatives (Parents of a minor, Guardians, and/or other Legally Authorized Representatives) of their rights to dispute resolutions at the time of service application, plan development, when changes are proposed, and upon request.
   • Types: Members, applicants, and their representatives will be informed of the regulatory requirement for Provider Agencies and CMAs to have separate dispute resolution policies and procedures. Whenever an adverse action is initiated by a Provider, they must issue a notice of action at least fifteen (15) days prior to the date actions become effective. If the member is dissatisfied with the proposed action, a resolution process can be initiated with the Provider Agency.  Receipt of the complaint by WCCMA shall initiate the CMA procedures.
   • Mode of Communication: Information will be provided in writing and orally, in English, and in the Member’s native language or through other necessary modes of communication upon request.
2. Filing a Complaint
   • Provider Procedure: If a Member or their representative disagrees with a decision/action by the Provider Agency or regional center, the member can file a complaint directly with the Agency to initiate the Agency mandated dispute resolution process per 8.7408.A.7:   
     • Provider Agencies shall have procedures for resolution of disputes involving Members:
       • Who were found not eligible or no longer eligible to receive the service(s) from the Provider Agency;
       • Whose services or supports are to be terminated; or,
       • Whose services set forth in the Person-Centered Support Plan are to be changed, reduced, or denied.
     • The procedure shall contain an explanation of the process to be used by Members, prospective Members, or Legally Authorized Representatives if they are dissatisfied with the decision or action of the Provider Agency.
     • The dispute resolution procedures of the Provider Agency shall, at a minimum, provide the parties with the opportunity to present information and evidence in support of their positions to an impartial decision maker. The impartial decision maker may be the director of the Agency taking the action or their designee. The impartial decision maker shall not have been directly involved in the specific decision at issue.
     • Provider Agencies shall supply Members with a Plain Language explanation of available dispute resolution procedures, along with outside Agency contact information, including phone numbers, for assistance.
   • CMA Procedure: If a Member or their representative disagrees with a decision/action by the Provider Agency or regional center, the member can file a complaint to WCCMA and request dispute resolution assistance. Receipt of this complaint initiates WCCMA’s dispute resolution procedure (this document).
   • Method: Complaints and requests for dispute resolution support can be submitted to your case manager by phone, email, fax, in-person, or though the WCCMA website.
     • Address: 315 N 11^th Avenue, Building C, Greeley, CO 80631
     • Website: Home and Community Supports
     • Fax: (970) 400-6671
   • Timing:
     • Response: WCCMA will respond to the complaint and request for assistance within two business days of receipt.
     • Notice of Action: An 803 Notice of Action will be issued no less than fifteen days before the implementation of any actions initiated by WCCMA.
3. Informal Negotiation Process
   • Procedure: WCCMA encourages resolving disputes through informal negotiation, including the possibility of mediation by a Case Manager, if both parties consent.
   • Timing: A meeting for negotiation must be scheduled with all parties or their representatives within fifteen days of receiving the Complaint.
4. Transition to Formal Dispute Resolution
   • Initiation: After opportunities for informal negotiation of the dispute have been attempted or mutually waived, either party may request to engage in the dispute resolution process set forth by WCCMA (see Procedure)
   • Formal Dispute Resolution Procedure: If informal negotiation fails, a formal dispute resolution process will be initiated. This process includes presenting evidence and arguments to an impartial decision maker who has not been directly involved in the dispute.
   • Due Process in Dispute Resolution
     • Impartial Decision Maker: The opportunity for the parties to present information and evidence in support of their positions to an impartial decision maker, who may be the director of the Agency or their designee. This impartial decision maker will not have been directly involved in the decision in question.
     • Advance Meeting Notification: Timely notification of the meeting, at least ten days in advance, provided to all parties, unless this requirement is waived by those objecting.
     • Legal Representation: The right to be represented by counsel, a Legally Authorized Representative, or another chosen individual if desired by the objecting party.
     • Response and Questioning: The chance to respond to or question the opposing position, ensuring a fair hearing.
     • Recording the Proceedings: The procedure will be recorded either by an electronic device or a reporter to maintain an accurate record of the proceedings.
     • Decisions and Rationale: A written decision will be issued within fifteen days after the meeting, detailing the reasons for the decision.
     • Option for Review: Should the dispute remain unresolved, the objecting party is notified of their right to request a review of the decision by the Executive Director of the Department or their designee.
     • Departmental Notification: WCCMA will inform the Department of all ongoing disputes and the decisions rendered.
5. HCPF Review
   • Procedure: A request for review by the Executive Director of the HCPF must be submitted within fifteen working days from the postmarked date of the decision, including a detailed statement of dispute and relevant information or evidence.
   • Review Process: The Executive Director, or designee, may request additional information from the CMA, which will be provided within fifteen working days of submission.  The Executive Director of HCPF or designee may request oral arguments or a hearing to render a decision.  A decision shall be rendered within ten working days of the submission of all relevant information.
6. Final Agency Action
   • The decision by the Executive Director of the HCPF is deemed the Final Agency Action regarding the dispute.
7. Emergency Termination of Services
   • Criteria: No Member may be terminated from services during the dispute resolution process unless an emergency that meets criteria set forth in Section 8.7000.A.4 is determined by the Department.

Rights and Protections

• No Prejudice: Engaging in the dispute resolution process will not affect the future provision of services.
• Protection from Coercion: Individuals are safeguarded against any form of coercion, intimidation, threats, or retaliation for participating in the dispute resolution process.
• Preservation of Legal Requirements: Participation in this dispute resolution process does not eliminate or reduce the requirements set forth by other legal mandates, such as the Long-Term Care Waiver Program Notice of Action (LTC-803). This ensures that the dispute resolution process complements rather than conflicts with existing legal frameworks, providing a comprehensive approach to resolving disputes.
• Accessibility and Inclusivity: The dispute resolution documentation will be available in English; however, to accommodate the diverse needs of our community, translations into other languages and alternative communication methods will be provided upon request.

Dispute Resolution Timeline Summary

To ensure clarity and adherence to the process, the following timelines summarize key procedural steps:

• Complaint Filing: A notice of action must be issued no less than fifteen days before the implementation of any actions detailed in Section 8.7202.S.1.
• Informal Negotiation Meeting: Scheduled within fifteen days of receiving the complaint.
• Formal Dispute Resolution Meeting Notification: At least ten days prior to the meeting.
• Issuance of Written Decision: Within fifteen days of the formal resolution meeting.
• Request for Department Review: Submitted within fifteen working days from the postmarked date of the decision.
• Department Review Decision: Rendered within ten working days of receiving all relevant information.
• Emergency Termination of Services: Only applicable under emergency criteria, with specific timelines dictated by the nature of the emergency as defined in Section 8.7000.A.4.

Policy Review

This policy will be updated as needed based on feedback and changes to contractual and regulatory requirements.