Grievances are written complaints made by a Member, dependent, and/or guardian regarding Carisk’s quality of service, quality of care, access or availability, provision of services, and claims administration. A grievance may also include a complaint related to an adverse determination made pursuant upon utilization review.

All staff will be educated concerning the importance of the grievance procedure and the rights of the subscriber, dependent, and/or guardian that have submitted the formal complaint.

• When not delegated contractually, Carisk will coordinate and cooperate fully with the appropriate contracted Health Plan to assist in the resolution of the grievance.
• Administrative and clinical staff will be available to assist or coordinate the grievance procedure with contracted Health Plans.
• All formal grievances may be filed no later than one year from the time of occurrence. The formal grievance must be completed in writing and submitted to Carisk.
• The Member, dependent, and/or guardian expressing their dissatisfaction, will receive an acknowledgement letter and a copy of the Grievance Procedures within five (5) working days of Carisk’s receipt.
• All grievances will be documented and tracked for accurate resolution within the required time frames. Grievance documentation may include, but is not limited to:
  
  • Assessment of Carisk’s responsibilities
  • Background information as it pertains to the formal complaint
  • Discussion(s) with any individual relevant to the formal complaint

The Member, dependent, and/or guardian expressing their dissatisfaction, has the right to receive assistance from any Carisk contracted network Provider, administrative or clinical staff during the grievance procedure. Carisk will process all formal grievances within a reasonable time not to exceed sixty (60) days from the initial filing of the formal complaint.

• If the grievance involves the collection of information outside the service area, Carisk will have an additional thirty (30) days to process the grievance through all grievance levels.
• The individual petitioning the grievance will be notified in writing regarding the need for the time extension.
• Upon Carisk’s receipt of the requested information, the time for completion of the formal grievance resumes with resolution and notification completed within ninety (90) days from the initial filing of the grievance.
• The Grievance Committee will notify the subscriber, dependent, and/or guardian of their findings within seven (7) working days of receiving the requested information with the resolution and notification completed within ninety (90) days from the initial filing of the grievance.

If you require assistance through a bilingual staff member or an interpreter, Carisk can provide language assistance  and information written in other languages free of charge to the Member. Should you require TDD/TTY services, please contact us at 305.514.5399, or toll free at 855.276.7285.

If Carisk is unable to resolve the formal grievance to the satisfaction of the Member who submitted the formal grievance, Carisk shall notify the subscriber, dependent, and/or guardian of their right to appeal to the Agency for Health Care Administration (AHCA).

Continuity and Coordination among all levels and practitioners of behavioral health care and primary care physicians (PCPs) is monitored and expected by Carisk. For inpatient admissions, coordination starts with the notification of the admission to the patient’s PCP and then at discharge by providing the PCP with the discharge summary. Should the discharge plan include a referral to Partial Hospital Program, IOP (intensive outpatient program), or outpatient counseling or treatment, the PCP needs to be informed by progress reports or summaries at each level of care by the practitioner(s) at that level of care. Continuity and coordination with the PCP is also essential if the Member accesses outpatient visits and does not require more intensive levels of behavioral healthcare. The frequency required for outpatient practitioner’s coordination is dependent on the diagnosis and treatment. Coordination with the PCP is essential when medication is prescribed and/or modified. Another area of continuity and coordination between behavioral health and PCPs is in reporting the results of psychiatric consultations performed at hospitals and nursing homes. The attending physician requesting the consult benefits from the timely receipt of the report of the psychiatric consultation and may need or wish to discuss the consult with the Psychiatrist.

Continuity and coordination across the continuum between all levels of behavioral healthcare is considered a reasonable standard of practice. If the inpatient attending is not the outpatient practitioner, notification at the point of admission, and again at discharge, is essential to maintain continuity of care. Coordination between outpatient practitioners with a shared client (split treatment) is essential in providing quality care. Carisk monitors and expects coordination between all levels of behavioral healthcare.

Carisk is aware of the need for a release of information in order to coordinate with both the PCP and other behavioral healthcare practitioners, and that some individuals are reluctant to sign the release. Carisk expects the reluctant individual to be educated by the behavioral healthcare practitioner regarding the importance of sharing information among those practitioners who are providing care and services.