Grievance/Complaint Procedure

Case Management Grievance/Complaint Procedure and Dispute Resolution Procedure

If you are dissatisfied with a decision or an action that A&I Avenues makes, you can file a complaint and ask to tell your side of the story to the people who made the decision.

Filing a complaint will never cause you to be terminated from your waiver/program or to be without any services at all. You cannot be coerced, intimidated, threatened or retaliated against because you have filed a grievance/complaint or have participated in the grievance/complaint process. Additionally, if you file a grievance/complaint it will not affect you being able to receive the appropriate services and supports to meet your needs.

When you file a complaint, this is what will happen:

Within 10 days, your Case Manager/Navigator will schedule an informal meeting with everyone involved in the decision to try and take care of the problem.

Mediation can also be used as an alternative to the informal meeting if all parties are in agreement. Contact your Case Manager/Navigator for information regarding mediation

If the problem is not taken care of at the informal meeting, your Case Manager/Navigator will arrange for everyone to meet with the Director of Programs and Services or their representative. Everyone involved will be told about this meeting at least 10 days before the meeting unless everyone involved wants to meet sooner.

You can bring someone with you to help present your information. (See advocacy listings at the end of the document.)

Within 10 days after the meeting, you will get an answer from the Director of Programs and Services or their representative.

If anyone is still dissatisfied with the decision, the A&I Avenues Chief Executive Officer or their designee will review the decision and may need to call another meeting if more information is needed.

The A&I Avenues Chief Executive Officer or their designee will make a decision within 10 days. The A&I Avenues Chief Executive Officer’s decision is the final decision.

If your concerns are not addressed satisfactorily you may file a formal complaint with the Department of Health Care Policy and Financing (HCPF) through the complaint link (See contact information at the end of this document).

Dispute Resolution Procedure

A&I Avenues must notify you in writing at least 15 days prior to the date actions become effective if:

You are no longer eligible for services,
Your services are to be terminated, or
The services written in your individual plan are going to be changed, reduced, or denied.

If you are dissatisfied with a decision or an action that A&I Avenues makes, you can file a dispute with the A&I Avenues Chief Executive Officer and ask to tell your side of the story to the people who made the decision.

Filing a dispute will never cause you to be terminated from your waiver or to be without any services at all. You cannot be coerced, intimidated, threatened or retaliated against because you have filed a dispute or have participated in the dispute resolution process. Additionally, if you file a dispute it will not affect you being able to receive the appropriate services and supports to meet your needs.

When you file a dispute, this is what will happen:

Your Case Manager/Navigator will schedule an informal meeting with everyone involved in the decision to try and take care of the problem, or with mutual consent, the informal negotiation process can be waived and the formal dispute process to start immediately. The informal meeting must be held no more than 15 days after you file your dispute.

Mediation may be used as an alternative to the informal meeting if all parties are in agreement. Please contact your Case Manager/Navigator regarding mediation.

If the problem is not taken care of in the informal meeting, either you or A&I Avenues can ask that the Formal Dispute Resolution Procedure be started.

The Formal Dispute Resolution Process:

A&I Avenues will arrange for everyone involved to present information that supports his or her position to an impartial decision-maker. The impartial decision maker will not be anyone who is involved with the issue.

Everyone involved will be told about this meeting at least 10 days before the meeting unless waived by the objecting parties.

You can have representation by counsel, an authorized representative or another person present your case if you want.

You or your representative will be allowed to answer or ask questions of the opposing position. The meeting may be video or audio taped.

Within 15 days of the meeting, you will receive a written decision in the mail from the impartial decision maker.

If anyone is dissatisfied with the decision, either you or A&I Avenues may ask the Colorado Department of Health Care Policy and Financing to review the decision.

Within 15 days of the postmark on the written decision, the Colorado Department of Health Care Policy and Financing will be told about the problem and what has been done to fix it so far.

The Colorado Department of Health Care Policy and Financing may ask for more information or another meeting to help make a decision.

The Colorado Department of Health Care Policy and Financing will make a decision based on all of the information within 10 days of receiving all of the information.

The Colorado Department of Health Care Policy and Financing decision is the final decision.

Your services and supports will not stop during the Dispute Resolution Process unless HCPF decides that it is an emergency situation.

An emergency situation could include mistreatment, neglect, abuse, or exploitation or other situations that could result in harm to you or someone else.

If your concerns are not addressed satisfactorily, you may file a formal complaint with the Colorado Department of Health Care Policy and Financing through this link.

There are certain instances in which an individual may have the right to file an appeal (dispute) of a decision not only through HCPF but also through the Medicaid system. This is known as asking for a Medicaid Fair Hearing.

This applies only if you are currently receiving services through one of the 10 Medicaid waivers, not if you are in the application process for services in the Medicaid waiver system, and if you are receiving Medicaid funded services (not state funded services). To dispute initial eligibility decisions, a separate Conflict Resolution process is followed.

Your Case Manager can provide you with information on a Medicaid Fair Hearing.

Additional Resources:

Click HERE To submit a complaint to the Colorado Department of Health Care Policy and Financing

Advocacy Organizations:

Association for Community Living - 303-527-0888

The Legal Center - 303-722-0300