File a Grievance or Appeal

Mountain View PACE encourages open communication with all participants and their support systems. If, at any time, a participant is not satisfied with the care or services that they receive, we encourage the communication of that concern to their Mountain View PACE team. Mountain View PACE has a process that evaluates and resolves any grievances, whether medical or non-medical in nature, by its participants, their family members or representatives. Mountain View PACE will assure that every grievance is handled efficiently while maintaining open communication with the griever with the goal of resolving the grievance to the satisfaction of the concerned participant. If the Mountain View PACE team is not able to resolve the grievance to the satisfaction of the participant, further assessment of the grievance will be conducted by the Executive Director or Medical Director and/or by the Plan Advisory Committee with the continued goal of resolution to the satisfaction of the participant.

An appeal is defined as the participant’s and/or representative’s action with respect to Mountain View PACE non-coverage of, or non-payment for, a service including denials, reductions, or termination of services. A participant/family member/representative may file an appeal by communicating with any Mountain View PACE staff or by calling toll free 800-461-3920 (711 TTY). Mountain View PACE's request for an involuntary disenrollment may also be appealed. All requests for appeals will be treated in a confidential manner. Contracted providers will be held accountable to all Appeal Procedures established by Mountain View PACE, as outlined in the Contracted Provider’s Manual.

The appeals process will be reviewed with participants/ family members/ representatives upon enrollment, in writing to the participants and/or responsible parties annually, and whenever the Interdisciplinary Team denies a request for service or payment. Upon Enrollment, at least annually thereafter, and whenever the Interdisciplinary Team denies a request for services or payment, Mountain View PACE will provide the participant oral and written information on the appeals process. Beneficiary notification will include the availability of assistance with completing an appeal.

Mountain View PACE will observe timely preparation and notice of a written denial of coverage or payment. Notice must include specific reasons for denial or non-payment, instruct Participant how to file an appeal if they do not agree with the action, and advise them of their right to request an expedited appeal process if they believe their life, health or ability to regain or maintain maximum function would be seriously jeopardized absent provision of the service in dispute.

If, during non-center operation hours, the participant/family member/representative wishes to file an appeal, the administrator on-call will be responsible for receiving and then communicating the appeal to the Center Manager the next business day. The Medicaid participant may request a State Fair Hearing after all attempts have been exhausted to resolve issues through the Mountain View PACE program.