- Phone number for oral requests: 1-877-998-LIFE
- Mailing Address for written requests: 401 Broad St., Johnstown, Pa 15906
- Fax number: 814-248-7878
Participant Grievance/Appeal Procedure
All of us at LIFE share the responsibility for assuring that you are satisfied with the care you receive. We ENCOURAGE you to express any complaints you have at the time and place any dissatisfaction occurs. To be consistent with federal regulations for the program, your complaints or dissatisfaction with our program or decisions are identified as either grievances or appeals. Those processes are described below.
The definition of a grievance is a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished.
- Discuss your grievance with any staff member. Give complete information so that appropriate staff can help to resolve your concern in a timely manner.
- The staff that receives your grievance will discuss with you and provide in writing the specific steps including time-frames for response that will be taken to resolve your grievance. The grievance will be reported to the health team within 5 working days.
- If a solution is found by the staff and agreed to by you and/or your family/caregiver within 5 working days of making the grievance, the grievance is resolved.
- If you are not satisfied with the solution, the staff will send a written report to the Executive Director (clinical complaints will be reviewed by qualified clinical personnel)for review, to be completed within 5 working days.
- Immediately after review (but within 5 working days), a copy of a written report will be sent to you and/or your family/caregiver.
- If you are still dissatisfied with the results, you may submit a request in writing within 30 days to ask for a review by LIFE's Plan Advisory Committee.
- The Plan Advisory Committee will send written acknowledgment of receipt of the grievance within 5 working days to you, investigate, find a solution and take appropriate actions.
- The committee will send you a copy of a report containing a description of the grievance, the actions taken to resolve the grievance and the basis for such action. The committee has 30 working days from the day the grievance is filed with the committee to complete its report and send it to you.
- If the decision is not in your favor, a copy of the report will be forwarded immediately to the federal government, the Pennsylvania Department of Public Welfare and the local Area Agency on Aging.
The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denial of enrollment, or your involuntary disenrollment from the program.
You will be notified in writing if we:
- will not cover or pay for a service that you are receiving or requesting;
- are denying enrollment into LIFE; or
- are initiating an involuntary disenrollment from LIFE.
The notice will instruct you how to appeal our decision if you do not agree with it. You must request an appeal within 30 days of our notice to you. An involuntary disenrollment for non- compliance with your care plan or conditions of participation, engaging in disruptive or
threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 days without prior approved arrangements, will automatically be considered an appeal.
- Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request.
- We will continue to furnish disputed services until a final determination is made if you appeal within 30 days of our notice to you; if we are proposing to terminate or reduce services you are currently receiving; and if you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor.
- An impartial party will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute.
- You will receive a written report of the third party review within 30 days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review.
- If your appeal is resolved in your favor, we will provide or pay for the disputed service right away.
- If the decision is not in your favor, a copy of the written report from the third party review will be forwarded immediately to the federal government, the Pennsylvania Department of Public Welfare and the Local Area Agency on Aging. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. We will assist you in choosing which to pursue and forward the appeal to the appropriate entity.
- If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that we speed up the appeal process. In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal.
Your Rights as a Participant
As a participant in LIFE you have the following rights:
- To have this Enrollment Agreement, all treatments and treatment options fully discussed and explained to you in a language you understand (which includes Braille ifnecessary).
- To be fully informed in writing in a language you understand, (which includes Braille if necessary) prior to and at the time of enrollment (as well as during participation) of the services available at the Center and in the program.
- To not be required to perform services for LIFE.
- To be fully informed of rights and responsibilities as a participant in LIFE and to exercise your rights as a participant. This may include voicing grievances and recommending changes in policies and services to Center staff and outside representatives of your choice. There will be no restraint, interference, coercion, discrimination or reprisal by the Center or its staff.
- To be fully informed of the appeal process, and be provided, by LIFE staff, any assistance needed to file an appeal, as outlined in LIFE’s appeal process.
- To be fully informed by the health team of your health and functional status.
- To participate in the development and implementation of your service plan designed to promote your functional ability to the optimal level and to encourage your independence. The health team must agree upon these services.
- To choose your health care provider from LIFE’s contracted network.
- To request a qualified specialist for women’s health.
- To access emergency services without prior approval.
- To request reassessment by the health team.
- To be given advance notice, in writing, of any transfer to another treatment setting.
- To receive information on advance directives and assistance in completing forms to carry out your wishes.
- To receive treatment and rehabilitation services.
- To be treated with dignity and respect, and be afforded privacy, confidentiality and humane care.
- To receive services in a culturally competent manner even if you have limited English language skills and a diverse cultural and ethnic background.
- To be free from harm, corporal punishment, unnecessary physical or chemical restraints, involuntary seclusion, physical or mental abuse or neglect.
- To be free from hazardous procedures.
- To have reasonable access to telephones.
- To be assured of confidential treatment of all information contained in your health record, including information contained in any automated data bank. We will require your written consent or authorization for the release of information to persons not otherwise authorized under law to receive it. You may provide written consent or authorization, which limits the degree of information and the persons to whom information may be given.
- To review your own records and to request and receive a copy of your medical records and to request that they be amended or corrected.
- To refuse treatment and be informed of the consequences of such refusal.
- To receive competent, considerate, respectful care from LIFE staff and contractors without regard to race, religion, color, age, sex, source of payment, national origin, sexual orientation or disability.
- To receive comprehensive health care in a safe and clean environment, and in an accessible manner.
- To be able to examine the results of the most recent review of LIFE conducted by the state and federal government.
- To end your participation in LIFE at any time subject to the terms of this agreement.
Participant and Caregiver Responsibilities
Participants and caregivers have the following responsibilities:
- Accept help from LIFE staff without regard to race, religion, color, age, sex, national origin or disability of the care provider.
- Keep appointments or notify LIFE if an appointment cannot be kept.
- Supply accurate and complete information to LIFE staff.
- Authorize LIFE to obtain and use records and information from hospitals, residential health care facilities, home health agencies, physicians and other practitioners who treat you.
- Authorize LIFE to disclose and exchange personal information with the federal and state government and their agents during reviews.
- Actively participate in care plan development.
- Inform LIFE of all health insurance coverage and notify LIFE promptly of any changes in that coverage.
- Cooperate with LIFE in billing for and collecting applicable fees from third party payers.
- Notify the County Assistance Office of the Department of Public Welfare and your LIFE social worker within 7 days of any changes in your income and assets. Assets include bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies and any other assets. The state operates a fraud control program under which local, state, and federal officials may verify the information you have given.
- Ask questions and request further information regarding anything you do not understand.
- Use LIFE designated providers for services included in the benefit package.
- Assist in developing and maintaining a safe environment for you, your family and your caregivers.
- Notify LIFE promptly of any change in address or lengthy absence from the area.
- Comply with all policies of the program as noted in this Enrollment Agreement.
- Cooperate in implementation of the care plan.
- Take prescribed medicines.
- If you get sick or injured, call LIFE for direction right away at (724) 838-8300.
- In case of emergency, call 911.
- If emergency services are required elsewhere or out of the service area, you must notify LIFE within forty-eight hours or as soon as reasonably possible.
- Notify LIFE in writing prior to disenrolling.
- Pay required monthly fees, if applicable.