Pathways Pace

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.

Pathways PACE Grievance Process

As a participant, you are encouraged to use the Pathways PACE internal grievance process for any concerns you may have. By voicing your concerns, the Pathways 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 Pathways 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 Pathways PACE program are always assured to be free from discrimination or any type of reprisal for voicing concerns. The Pathways 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 Pathways PACE’s non-coverage of or nonpayment for a service.
• Non-coverage of service: Pathways PACE denies providing a service requested by the participant or his/her legal representative.
• Nonpayment for a service: Pathways PACE denies payment for a service received by the participant.

Process

As a participant in the Pathways 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:

Pathways PACE
Quality Assessment Performance Improvement (QAPI)
1900 16th St.
Greeley, CO 80631
Attn: PACE Quality & Compliance Director

Upon receipt, Pathways 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, Pathways PACE will provide the service for as long as your health condition requires.

If you are currently receiving the disputed service, Pathways 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 Pathways Pace internal grievance and appeal process so that we may address your concerns as soon as possible. participants eligible for Pathways PACE 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. Pathways PACE staff will discuss your additional rights and processes at that time.

Medicare Appeal Process

Participants are encouraged to use the Pathways 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 Pathways 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 Pathways 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 720-903-9607. Pathways PACE supports and encourages you to access this valuable advocacy resource.