For CBH Members: Special Situations

DEPARTMENT OF PUBLIC WELFARE FAIR HEARING

In some cases you may ask the Department of Public Welfare to hold a hearing because you are unhappy about or do not agree with something CBH did or did not do. These hearings are called “fair hearings”. You may ask for a fair hearing at the same time you file a complaint or grievance or you may ask for a fair hearing after CBH decides your first or second level complaint or grievance.

What kind of things may I request a fair hearing about, and when do I have to ask for a fair hearing?

If you are unhappy because…	You must ask for a fair hearing…
CBH decided to deny a service because it is not a covered service.	Within 30 days of getting a letter from CBH telling you of this decision or within 30 days of getting a letter from CBH telling you its decision after you filed a complaint about this issue
CBH decided not to pay a provider for a service you received AND the provider can bill you for the service.	Within 30 days of getting a letter from CBH telling you of this decision or within 30 days of getting a letter from CBH telling you its decision after you filed a complaint about this issue
CBH did not decide your first level complaint or grievance within 30 days of when you filed it.	Within 30 days of getting a letter from CBH telling you that we did not decide your complaint or grievance within the time we were supposed to
CBH decided to deny, decrease or approve a service different than the service your provider requested because it was not medically necessary.	Within 30 days of getting a letter from CBH telling you of this decision or within 30 days of getting a letter from CBH telling you its decision after you filed a grievance about this issue
CBH provider did not give you a service by the time you should have received it. (CBH providers must provide services within one hour for emergencies, within 24 hours for urgent situations, and within seven days for routine appointments and specialty referrals. If a treatment plan is approved, services must be provided according to the prescribed treatment plan.)	Within 30 days from the date you should have received the service or within 30 days of getting a letter from CBH telling you its decision after you filed a complaint about this issue

How do I ask for a fair hearing?

You must ask for a fair hearing in writing and send it to:

Department of Public Welfare
Office of Mental Health and Substance Abuse Services
Division of Grievances and Appeals
Beechmont Building #32, 2nd Floor
PO Box 2675
Harrisburg, PA 17105-2675

Your request for a fair hearing should include the following information:

the member’s name
the member’s social security number and date of birth
a telephone number where you may be reached during
the day
if you want to have the fair hearing in person or by telephone
any letter you may have received about the issue you are
requesting your fair hearing for

What happens after I ask for a fair hearing?

You will get a letter from the Department of Public Welfare’s Bureau of Hearings and Appeals telling you where the hearing will be held and the date and time for the hearing. You will receive this letter at least 10 days before the date of the hearing.

You may come to where the fair hearing will be held or be included by phone. A family member, friend, lawyer or other person may help you during the fair hearing.

CBH will also go to your fair hearing to explain why we made the decision or explain what happened.

If you ask, CBH must give you (at no cost to you) any records, reports and other information we have that is relevant to what you requested your fair hearing about.

When will the fair hearing be decided?

If you ask for a fair hearing after a first level complaint or grievance decision, the fair hearing will be decided no more than 60 days from when the Department of Public Welfare gets your request.

If you ask for a fair hearing and did not file a first level complaint or grievance, or if you ask for a fair hearing after a second level complaint or grievance decision, the fair hearing will be decided within 90 days from when the Department of Public Welfare gets your request.

A letter will be sent to you after the decision is made. This letter will tell you the reasons for the decision. It will tell you what to do if you don’t like the decision.

What to do to continue getting services:
If you have been receiving services that are being reduced, changed or stopped, and your request for a fair hearing is hand-delivered or postmarked within 10 days of the date on the letter telling you that CBH has reduced, changed, or stopped your services, or telling
you CBH’s decision about your first or second level complaint or grievance, your services will continue until a decision is made.

What can I do if my health is at immediate risk?
Expedited Fair Hearing

Complaints | Grievances | Expedited Complaints and Grievances

DPW Fair Hearings | Special Situations