Patients' Rights Advocate

The Patients' Rights Advocate helps Medi-Cal beneficiaries and other consumers understand their rights and access problem solving processes. Duties include:

  • Providing written informational materials
  • Advocating for consumers
  • Investigating complaints
  • Monitoring programs to be sure that patients' rights are protected
  • Training providers and consumers about rights
  • Communicating with the State Patients' Rights Program

To get help from the Patients' Rights Advocate: 

Contact the Patients’ Rights Advocate (PRA) through one of the following ways:

Complete a Consumer Request Form to Report or Request:

  1. Complaint – referred to the appropriate supervisor and handled at that level. Complaints may be submitted by anyone. 
  2. Grievance – a Medi-Cal member’s expression of dissatisfaction about any matter, other than an appeal. If you are dissatisfied about the services or care you have received, you may file a grievance at any time. Within 5 calendar days of receiving a grievance, the PRA will send you an acknowledgement letter. The matter will be resolved within 30-days from the date the grievance is filed, and you will be notified in writing of the way the grievance is resolved. 
  3. Second Opinion – If you dispute a clinical decision, you can request a second opinion, which will be handled to the extent resources are available if the request is clinically indicated. A second opinion about prescribed medications will be reviewed by the Medical Director or designee. When the requested medication is potentially harmful or is inconsistent with sound medical practice, the Medical Director may not approve a second opinion. 
  4. Change of Provider – We will attempt to make changes when resources are available and when appropriate. 
  5. Standard Appeal- request for a review of a Notice of Adverse Benefit Determination (NOABD) of any denial, limitation, reduction, or suspension of services. Appeals must be filed within 60 days of the dated NOABD. Within 5 calendar days of receiving an appeal, the PRA will send you an acknowledgement letter. The matter will be resolved within 30-days from the date the appeal is filed, and you will be notified in writing of the way the appeal is resolved. 
  6. Expedited Appeal – if a standard appeal time frame would place you at risk, and expedited appeal may be requested. Expedited appeals are resolved within 72-hours, and a 14-day extension may be put in place. 

Consumer Request Forms are available at Behavioral Health clinic locations with pre-addressed postage paid envelopes or for download here: 

  1. Consumer Request Form in English 
  2. Consumer Request Form in Spanish 

FAQs

Medi-Cal beneficiaries have a number of rights, including the rights to be treated with dignity and respect. 

View a useful summary:

The links below have even more information about our services and your rights:

An appeal is a request by a Medi-Cal beneficiary, a beneficiary's representative, or a provider for a review of an "Action" or "Adverse Benefit Determination" taken by the County of San Luis Obispo Behavioral Health Department (SLOBHD). "Action" and "Adverse Benefit Determination" are the fancy terms used by the State to describe our decision to not give you a service you ask for. SLOBHD will always mail a written explanation of the action taken, and the notice will explain exactly how to file an appeal. The Patients' Rights Advocate (PRA) is available to help you file the appeal if needed. 

A client, provider, and/or authorized representative may file an appeal orally or in writing within 60 calendar days from the date on the Adverse Benefit Determination. Appeals filed by the provider on behalf of a client require written consent from the client/parent/legal guardian. SLOBHD will send written acknowledgement of all standard appeals within 5 calendar days of receipt. 

SLOBHD has 30 calendar days after we review your appeal to reach a resolution. If you believe that waiting that long will create a serious problem for you, please talk with the PRA about an expedited appeal. Expedited appeals will be expedited as medically necessary and resolved within 72 hours. 

If you do not agree with how your appeal is resolved, you have a right to file for a State Fair Hearing. State Fair Hearings must be filed with the state within 120 days from the date of the notice of appeal resolution. 

A grievance is when you tell us by phone, in person, or in writing that you are dissatisfied with something we've done, other than deny or reduce services (those are things you can appeal if you are a Medi-Cal beneficiary).

The Consumer Request Form is one way to let us know about your grievance, or you can call the Patients' Rights Advocate (PRA) at (805) 781-4738.

A client may file a grievance at any time. The PRA will send written acknowledgement of your grievance within 5 calendar days. The PRA will resolve grievances within 30 calendar days.

A Fair Hearing is an independent review conducted by the California Department of Health Care Services and the California Department of Social Services to make sure that Medi-Cal beneficiaries receive the services to which they are entitled. Beneficiaries must first file an Appeal and wait for SLO Behavioral Health to resolve the Appeal. A Fair Hearing may then be requested if the  Appeal or Expedited Appeal was not decided completely in the Medi-Cal beneficiary's favor. 

The Patients' Rights Advocate is available to help file the Fair Hearing Request. Directions are on the Consumer Request Form.

Reference