Section DHS 10.53 - Grievances and appeals(1) GRIEVANCE PROCESS IN RESOURCE CENTERS. (a) The governing board of each resource center shall approve and effectively operate a process for reviewing and resolving client grievances. The board may delegate, in writing, its responsibility for reviewing and resolving grievances to a committee of the resource center's senior management, provided the process ensures that the board is made aware of grievances and requests for department review and fair hearings.(b) The department shall review and approve a resource center's grievance process as part of its contracting with the resource center.(c) A resource center shall inform clients of all of the following:1. The circumstances under which expedited resolution of a grievance is available and how to request it.2. The client has the right to appear in person before the resource center personnel assigned to resolve a grievance filed, if the enrollee files the grievance.3. The availability of independent advocacy services and other local organizations that might assist a client with a grievance.4. The client may obtain, free of charge, copies of client records relevant to the grievance and how to obtain the copies.(d) A resource center shall assist individuals with the filing of grievances with the resource center.(e) A client may file a grievance with the resource center at any time.(f) The resource center shall complete its review of a grievance and issue its written decision to the client within 10 business days of its receipt of the grievance, unless the client and the resource center agree to an extension for a specified period of time.(1m) APPEALS PROCESS IN RESOURCE CENTERS. (a) Resource center adverse benefit determinations are appealed through the fair hearing process under s. DHS 10.55.(b) A resource center shall assist clients with the filing of requests for fair hearings with the division of hearings and appeals.(2) GRIEVANCE AND APPEALS PROCESS IN CARE MANAGEMENT ORGANIZATIONS. (a) The governing board of each CMO shall approve and shall effectively operate a process for reviewing and resolving enrollee grievances and appeals. The board may delegate, in writing, its responsibility for reviewing and resolving grievances and appeals to a committee of the CMO's senior management, provided that the board is made aware of grievances and requests for department review and fair hearings.(b) The department shall review and approve a CMO's grievance and appeal process as part of its contracting with the CMO.(bg) An enrollee may file a grievance at any time.(br) The CMO shall complete its review of a grievance and issue its written decision to the enrollee within 90 days of its receipt of the grievance, unless the grievance decision timeframe is extended under the extension requirements specified in the contract with the department.(c) The CMO shall inform enrollees of all of the following:1. The circumstances under which expedited resolution of a grievance is available and how to request it.2. The enrollee has the right to appear in person before the CMO personnel assigned to resolve a grievance, if the enrollee files the grievance.3. The availability of independent advocacy services and other local organizations that might assist an enrollee with a grievance.4. The enrollee may obtain, free of charge, copies of enrollee records relevant to the grievance and how to obtain the copies.(d) A CMO shall assist enrollees with filing grievances with the CMO. If an enrollee is dissatisfied with the CMO's grievance decision, or the CMO fails to render a grievance decision within the timeframe specified under par. (br), a CMO shall assist the individual with requesting a department review of the grievance under s. DHS 10.54.(dm) An enrollee must request department review within 45 days of the date on the grievance decision.(e) The CMO shall complete its review of an appeal and issue its written decision to the enrollee within 30 days of its receipt of the appeal, unless the appeal decision timeframe is extended under the extension requirements specified in the contract with the department.(f) A CMO shall assist enrollees with filing appeals with the CMO. If the enrollee is dissatisfied with the CMO's appeal decision, or the CMO fails to render an appeal decision within the timeframe specified under sub. (2) (e), a CMO shall assist the individual with requesting a fair hearing with the division of hearings and appeals under s. DHS 10.55.Wis. Admin. Code Department of Health Services DHS 10.53
Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a) to (c) and (2) (a) to (c) Register November 2004 No. 587, eff. 12-1-04.Amended by, CR 22-026: am. (title), (1) (a), (b), renum. (1) (c) to (1) (c) (intro.) and am., cr. (1) (c) 1. to 4., (d) to (f), (1m), am. (2) (title), (a), (b), cr. (2) (bg), (br), r. and recr. (2) (c), cr. (2) (d) to (f) Register May 2023 No. 809, eff. 6-1-23; correction in (2) (d), (f) made under s. 35.17, Stats.,correction in numbering of (2) (dm) made under s. 13.92 (4) (b) 1, Stats., and correction in (2) (f) made under s. 13.92 (4) (b) 7, Stats., Register May 2023 No. 809, eff. 6/1/2023