Section 141.250  Participant Appeals

For appeals by individuals or their authorized representatives regarding CMH-HCBS participation or services, the following shall apply:

a)         The individual, parent or legal guardian, or authorized representative may appeal the following issues:

1)         Failure to take action on a request for eligibility determination or a request for services;

2)         Denial of a request for CMH-HCBS eligibility or a request for services;

3)         Any action by the Department to reduce, change, suspend or terminate any service; or

4)         Termination of eligibility for CMH-HCBS.

b)         The Department rules for Assistance Appeals (89 Ill. Adm. Code 104.Subpart A) shall apply to all appeals under this Section, except that informal review of a denial of a request for CMH-HCBS eligibility or termination of eligibility for CMH-HCBS must be completed by the Department's Bureau of Behavioral Health pursuant to this Section before formal appeal of the issue may be requested to the Department's Bureau of Administrative Hearings (BAH).

1)         Request for informal review must be submitted in writing to the Bureau of Behavioral Health within 20 days after the date of notice of the contested action and must clearly identify the issue or action for which informal review is sought.

2)         If the request for informal review is received by the Bureau of Behavioral Health prior to the Department's intended action taking effect, the action shall be stayed through the completion of the informal review and the subsequent 10 day period to formally appeal the outcome of the informal review to the BAH pursuant to 89 Ill. Adm. Code 102.81.

3)         The Bureau of Behavioral Health shall complete the informal review of the contested action within 30 days after receipt of the request and shall determine whether to maintain, reverse or modify the action, or take other action as necessary.

A)        The Department may request and review all materials pertaining to the informal review held by the Department's vendors, agents or providers.

B)        The Department shall provide written notification to the individual or authorized representative of the result of the informal review, consistent with 89 Ill. Adm. Code 102.70.

4)         The individual, parent or legal guardian, or authorized representative may appeal the outcome of the informal review to the BAH within 60 days after the date of notice of the outcome of the informal review, pursuant to 89 Ill. Adm. Code 102.82.