Grievance and Appeal Process

As a participant, you are entitled to notify team members of your concerns and complaints by filing a grievance. Your social worker can assist you in determining the appropriate method to resolve the issue.

Colorado PACE Grievance Process

As a participant, you are encouraged to use the Colorado PACE internal grievance process for any concerns you may have. By voicing your concerns, the Colorado PACE Team has an opportunity to address your issues as soon as possible.

Grievance is appropriate for reporting:

  • An act that is, or may be, below the applicable standard of care.
  • An act or lack of action which has a reasonable probability of causing injury or hardship for a participant, family, or employee.
  • A concern or complaint related to services regardless of source.
  • Any issue related to the safety for participants or staff.

Process

Your concerns may be voiced to any staff member who will then assist you to document and report your issues directly to the Colorado PACE Team. Once the team has received your concern, they will respond with a proposed resolution seeking your satisfaction with the outcome.

Participants in the Colorado PACE program are always assured to be free from discrimination or any type of reprisal for voicing concerns. The Colorado PACE Team is committed to ensuring that you are satisfied with the services provided.

Colorado PACE Appeal Process

Definitions

  • Appeal: A participant’s action taken with respect to Colorado PACE’s non-coverage of or nonpayment for a service.
  • Non-coverage of service: Colorado PACE denies providing a service requested by the participant or his/her legal representative.
  • Nonpayment for a service: Colorado PACE denies payment for a service received by the participant.

Process

As a participant in the Colorado PACE Program, you have the right to appeal any decision the team makes relating to a denial of service or for the nonpayment of a received service. The team must notify you, both orally and in writing, within five days of the decision.

You will receive a description of the denied service, the reason for the denial and your appeal rights. You have 30 days from the date of the denial letter to file a written appeal. If you need assistance, please contact your social worker.

Make your appeal to the attention of:

Colorado PACE

Quality Assessment Performance Improvement (QAPI)

8289 E Lowry Boulevard

Denver, CO 80230

Attn: Compliance Officer

Upon receipt, Colorado PACE will assign an impartial third party who was not involved in the original decision to conduct a review of the dispute. The panel will maintain your confidentiality during the review process.

You will have an opportunity to present your concerns related to the dispute in-person as well as in writing. Within 30 days of filing your appeal, the panel must notify you of their findings in writing. If the panel finds in your favor, Colorado PACE will provide the service for as long as your health condition requires.

If you are currently receiving the disputed service, Colorado PACE will continue to provide the service with the understanding that you may be liable for the cost if the determination is not in your favor.

Medicaid Appeal Process

You are encouraged to use the Colorado PACE internal grievance and appeal process so that we may address your concerns as soon as possible. participants eligible for Colorado Medicaid can appeal to the State of Colorado and must ask for a hearing in writing. This is called a Letter of Appeal.

Your letter of appeal must include:

  • Name, address, phone number and Medicaid number.
  • Clarify why you want a hearing.
  • A copy of the front page of the notice of action you are appealing.
  • You may ask for a telephone hearing rather than appear in person.

Mail or fax your letter of appeal to:

OFFICE OF ADMINISTRATIVE COURTS

1525 Sherman Street, 4th Floor

Denver, CO 80203

Fax 303-866-5909

  • Your letter of appeal must be received by the Office of Administrative Courts no later than sixty (60) calendar days from the date of the notice of action.
  • The Office of Administrative Courts will contact you by mail with the date, time, and place for your hearing with the Administrative Law Judge.

Continued Benefits

To continue receiving the denied services, you must file your request for a hearing in writing no later than 60 calendar days after the date on the notice of action. You may continue receiving services while you are waiting for a decision on your appeal. If you lose your appeal, you must pay back the cost of the services you received during the appeal. If you win your appeal, the State will pay your provider for the service(s) you received during your appeal process. Your provider is responsible for reimbursing you for the amount you paid them during your appeal.

If you have questions about the appeal process, please call:

Health First Colorado Member Contact Center

1-800-221-3943

State Relay 711

Se Habla Español

Upon admission to an assisted living facility or nursing home, you may have additional grievance rights and processes available to you. Colorado PACE staff will discuss your additional rights and processes at that time.

Medicare Appeal Process

Participants are encouraged to use the Colorado PACE internal grievance and appeal process so that we may address your concerns as soon as possible; however, participants eligible for Medicare may request Reconsideration. Participants may appeal through this process; however, it is the Colorado PACE organization’s responsibility to file the Medicare appeal on your behalf.

Maximus Federal Services

Medicare Managed Care and PACE

Reconsideration Project

3750 Monroe Avenue, Suite 702

Pittsford, New York 14534-1302

1-888-866-6205 (Telephone)

1-585-425-5292 (Fax)

Any participant who is eligible for both Medicare and Medicaid may choose to file an appeal with either Medicaid or Medicare, but not both.

As a Colorado PACE participant, you have the benefit of access to your PACE Ombudsman any time. An Ombudsman is available to help you advocate for your needs. Your PACE Ombudsman is available by calling 303-480-6734. Colorado PACE supports and encourages you to access this valuable advocacy resource.