Philadelphia Community Services for Children and Adolescents

Appendix E: What To Do if You Disagree with Your Behavioral Health Contractor

Trying to secure the proper medical care for your child can be a stressful process. Sometimes services may be denied to your child by the public health system that you believe your child needs. When there is a discrepancy between the services provided and the services desired, you have the right to have your voice heard. This section contains information about how to secure the treatment you think your son or daughter needs.

A. If You Disagree With Community Behavioral Health (CBH)

Important Note: The grievance and appeal rights spelled out below do not apply where a psychiatrist, psychologist or other treatment provider not working for CBH, the County MH/MR or its Base Service Units refuses to prescribe the type or amount of services the consumer (or family) feels he/she needs. For example, if a psychologist or psychiatrist refuses to request the number of wraparound hours a family feels their child needs (and therefore, the behavioral health contractor never gets to deny the request), the family would not be able to file a grievance with the behavioral health contractor or an appeal with DPW.

If you are unhappy with any of the services provided through or in conjunction with the public mental health system, you have options available to you that allow you to express your discontent. You can call CBH at 1-888-545-2600. Ask to speak with your Member Service Representative. It is also a good idea to ask for a copy of the CBH Member Handbook, if you do not already have one. Write to CBH at:

Community Behavioral Health
Attn: Quality Management Department
714 Market Street, 5th Floor
Philadelphia, PA 19106

Contact the Ombudsperson at 215-923-9617. The Ombudsperson is your advocate. This means that his or her job is to help you with mental health or substance abuse concerns. He or she is there to help when you have a problem with your services, want to make a complaint, a grievance, or if you need to file an appeal. The Ombudsperson can talk with you about your problem, help you write letters and fill out forms about your concern.
File a complaint
File a grievance

1. Filing a Complaint

You file a complaint when you are unhappy with CBH or your provider. A complaint is when you do not like the care you are getting from your provider - for example, your therapist, an intensive outpatient program or a hospital. A complaint is also when you do not like certain things about CBH, such as how they respond to your phone call or how quickly they give you service.

To file a complaint, you can call or write CBH (see above) and tell them "I have a complaint." CBH will investigate and review your complaint in 30 days or less. When CBH has finished the review, they have five business days to send you a letter that states what they decided about your complaint and why.

If you do not like CBH's answer to your complaint, you can take your complaint to the Second Level where a group of people (committee) meet to look at your concern. This group has people who use Mental Health and/or Substance Abuse services on it. You are allowed to attend this meeting and voice your complaint. You can bring friends, family, an advocate like the Ombudsperson, your provider, a lawyer or any other person to help you at the meeting. CBH has 30 days to look into/investigate your concern. CBH must then send you a letter within five business days that tells you what they decide and why.

If you are still not happy with CBH's answer to your complaint, you can file an "appeal of complaint." You must file an "appeal of complaint" within 15 days after you get CBH's letter that tells you what CBH decided about your complaint. To file the appeal, you must write a letter about your complaint and send it to the Pennsylvania Department of Health OR the Pennsylvania Insurance Department in Harrisburg (depending on the nature of your complaint). CBH or the Ombudsperson can help you write this letter.

If your complaint is about A PROVIDER AND ITS SERVICES, you send your letter to the Pennsylvania Department of Health at this address:

Bureau of Managed Care
Department of Health
Attention: Complaint Appeals
PO Box 90
Harrisburg, PA 17108-0080

If your complaint is about CBH AND THEIR POLICIES AND PROCEDURES, you send your letter to the Pennsylvania Insurance Department at this address:

Pennsylvania Insurance Department
Bureau of Consumer Affairs
1321 Strawberry Square
Harrisburg, PA 17120

If you are not sure where to send your appeal letter, call CBH or the Ombudsperson for help. If you send your letter to the wrong department, it will be forwarded to the right one. You may send any other information with your letter that you think may help with your complaint.

2. Filing a Grievance

You file a grievance when you are unhappy with CBH because they decided to:

Deny a service. For example, to say: "You can't stay in the hospital."
Decrease a service. For example, to say: "You can only see your Doctor one time a month instead of two times a month."
Approve a service different than the service your provider asked for. For example, to say: "You can't go to the hospital, but you can go to see a psychiatrist."

To file a grievance, you can call or write CBH and say "I have a grievance." CBH will investigate and review your complaint. They have 5 days to do this. After CBH reviews your grievance, CBH has 5 business days to send you a letter that states what they decide about your grievance and why.

If you do not like CBH's answer to your grievance, you can take your grievance to the Second Level where a group of people (committee) meet to look at your concern. This group has people who use Mental Health and/or Substance Abuse services on it. You are allowed to attend this meeting and voice your grievance. You can bring friends, family, an advocate like the Ombudsperson, your provider, a lawyer, or any other person to help you at the meeting. CBH has 30 days to look into/investigate your concern. CBH must then send you a letter within 5 business days that tells you what they decide and why.

If you are still not happy with CBH's answer, you can ask for another review of your grievance. To do this, you need to file an appeal. If you want to appeal a grievance, you can ask for an External Grievance Review. An External Grievance Review is when someone outside of CBH, but not the State, reviews your grievance.

a. External Grievance Review

To ask for an External Grievance Review, you must write a letter to CBH. If you need help writing this letter, CBH or the Ombudsperson can help you. You must ask for the External Review within 15 days of receiving CBH's denial letter (the letter that says what CBH decided at your Second Level grievance review). CBH will tell you the name, address and phone number of the place that will do the external review. You can send any information that you think will help your case to the external reviewer. You will get a letter from the external reviewer that tells you what they decide within 60 days of when you asked for the external review.

b. Pennsylvania Department of Public Welfare (PA DPW) Fair Hearing

You have the right to take a grievance directly to PA DPW and ask for a hearing anytime you get a letter denying your services. You only have 30 days from the date on the denial letter to take your complaint to PA DPW, however. And, if your grievance is about a service you are now getting (a continuing benefit), you must write to PA DPW within 10 days of the date on the denial letter you received from CBH in order to keep you services going.

To ask for a Fair Hearing from PA DPW, send a letter to or call the Pennsylvania Department of Public Welfare.

B. Getting Help

Material for this appendix was adapted from "The Member Handbook" produced by The Behavioral Health System of Philadelphia.