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It is important for you to know you have many rights and responsibilities when you enter into counseling. The following list outlines them.

You Have a Right…

• To considerate and respectful care which includes freedom from any physical, sexual, fiduciary (financial), or psychological abuse including humiliating, threatening, and exploiting actions;
• To understand what your problem is, what treatment is recommended and why, who will give the treatment, and what outcome to expect;
• To be involved in a process of informed choice, informed refusal, and/or expression of choice related to preference of your treatment services, choice of service provider and participation in research projects;
• To expect that all communications and records pertaining to your care will be treated as confidential;
• To have continuity of care when you are referred for services outside this agency;
• To examine and receive an explanation of your bill.
• To participate in all aspects of your treatment, including development of your treatment plan.
• To have access to self-help and advocacy support services.
• To voice complaints or lodge an appeal without recrimination.
• To have the right to refuse or terminate services, except where services are required by court order.
• To all legal protection and due process for status as an outpatient and inpatient, both voluntary and involuntary, as defined under Vermont law.

Your Responsibilities Are…

• To be honest in your presentation of your problems and to tell those working with you how you feel about what is happening to you.
• To be actively involved in the development of your treatment plan that will outline your problems, needs, goals, and expected outcome;
• To be considerate of others and their privacy;
• To present to your counselor any questions, complaints or concerns about your counseling plans or goals so that you may reach an agreement on any problem hindering your progress.

• Vermont Care Partners
• Champlain Community Services
• Clara Martin Center
• The Counseling Service of Addison County, Inc.
• Families First
• Green Mountain Support Services
• Health Care and Rehabilitation Services
• Howard Center
• Lamoille County Mental Health Services
• Lincoln Street
• NFI Vermont, Inc.
• Northeast Kingdom Human Services
• Northwestern Counseling and Support Services
• Rutland Mental Health Services
• Washington County Mental Health Services, Inc.

The pharmacy:

• Fills all medications (not just behavioral health)
• Mails all medications (at no extra cost) or you can pick them up at curbside
• Organizes your pills based on the date and time you need to take them, making it easy to stay on track
• Helps you transfer prescriptions from other pharmacies

Switch to a better pharmacy today!

Open Monday through Friday 8:30am to 5:00pm.(Closed from 12:30pm to 1:00pm.)

Located within United Counseling Service
100 Ledge Hill Drive
Bennington, VT 05201
Phone: 802.681-4011
Fax: 802.448-6871

Gross Family Income

Schedule of Fees

As an employee, intern, volunteer, or contractor of UNITED COMMUNITY SERVICES, INC. (“UCS”), its subsidiary or affiliate, I believe in the dignity of each client and commit myself to increasing each client’s level of independence. As a professional, I will assist in promoting the full development of each client’s potential. As a condition of continued employment, I understand and agree that I, as well as all employees and other individuals providing services on behalf of UCS, am required to conduct myself in an ethical and professional manner at all times. Should I be uncertain as to the interpretation of these standards, I will seek advice from my immediate supervisor, division director, corporate compliance officer, or the director of Human Resources.

I. GENERAL RESPONSIBILITIES

A. I will facilitate services that effectively meet the individual needs of our clients. I will seek required guidance and assistance from staff and others to ensure the highest quality of service delivery and to resolve any problem that may impair my performance.

B. I will promote a respectful and therapeutic atmosphere, demonstrating through my actions and involvement, my unique skills to assist client with a healthy adjustment to life.

C. I will always maintain professional objectivity and self-discipline so that each client’s needs remain my primary focus.

D. I am aware of the sensitivity of my work, its social impact, and the need to continually maintain appropriate boundaries both during and following my employment at UCS. I will make every effort to avoid relationships that could impair my professional judgment or impact the trust of the public or my colleagues. Developing relationships of a personal nature with open UCS clients is not appropriate or permitted. Communicating with clients on personal social media platforms should be prevented and avoided as it violates such professional boundaries. In cases where I have an existing personal relationship with someone who becomes a client in my program or Division, I will inform and seek guidance from my supervisor. Relationships with client family members are also not appropriate and there are risks in blurring the boundaries of your professional relationship.

E. I will continually offer and participate in professional training, as is appropriate to my profession and position with UCS, understanding that I have an obligation to remain proficient and competent in the delivery of my professional services.

F. I will not discriminate against or refuse professional services to anyone on the basis of race, color, ancestry, religion, sex, gender identity, sexual orientation, age, marital/civil union, national origin, citizenship, place of birth, ancestry, military/uniformed services or veteran status, disability, genetic information, having a positive test result on an HIV related blood test or other legally protected classification.

G. I will not participate in or condone any form of harassment or discrimination. Should I witness or find myself as a bystander to any form of harassment or discrimination by another employee or individual performing services on behalf of UCS, I will promptly notify my supervisor, the Director of Human Resources, or the Executive Director. I will actively seek to promote respectful communication in my role, as a colleague or as a bystander.
H. I will not assume professional responsibility for clients served by a colleague without appropriate consultation with that colleague except in cases of clinical emergency and when consultation is not indicated or available.

I. I will, should I be called upon to supervise other employees, evaluate their performance in a responsible, fair, considerate, and equitable manner.

J. I will be sensitive and aware of cultural, ethnic and gender diversity and respect the individuality provided by the differences among us.

K. I will complete all documentation, including but not limited to, client records, billing records, and timesheets in an accurate, timely and complete manner. Furthermore, I will not knowingly permit others to falsely submit records and, if I obtain such knowledge, I will notify the UCS Compliance Officer.

L. I will engage in safe work practices and promote health and safety in the workplace and will comply with all UCS policies, rules, and regulations pertaining to health and safety.

M. I have reviewed and will comply with the UCS Personnel Policies and Procedures, in particular the policy on Professional Conduct found at Section IV Division H and Section IX related to Health Safety and Security requirements.

N. I have reviewed and will comply with my Division’s Operations Manual.

II. ADVOCACY OF RIGHTS OF CLIENT

A. I will work to ensure that the legal rights of each client are not violated or denied in any way. I will act in accordance with standards of professional integrity, including any ethical requirements related to any professional licensure or certification that I hold.

B. I am dedicated to the development of each client’s independence and inclusion in the community.

C. I will do my best to ensure that co-workers, fellow professionals, and UCS respect the rights of the client.

D. I will do my best to ensure all clients’ rights to privacy, including those rights presented in UCS’s Notice of Privacy Practices are followed. I will report any violations to the Compliance Officer, the Privacy Officer, the Security Officer or report using the UCS compliance hotline.

E. I will provide assistance to a client wishing to register a complaint, grievance and/or appeal relating to the quality or quantity of services and will ensure that no retaliation occurs against that client for doing so.

F. I have reviewed and will comply with both the UCS Bill of Rights for Clients and the UCS Personnel Policies and Procedures, in particular Section VIII related to Administration and Section X related to Compliance requirements, relating but not limited to the privacy rights of clients.

III. ETHICS

A. I will, when disseminating or sharing non-client information, acknowledge and reference any sources of published information.

B. I will not place myself in a position where I am under obligation to any person who might benefit from special considerations or favors. I will not seek in any way to gain special treatment from other clients which could compromise UCS. This includes other health care providers, outside vendors, community members, and any other business-based relationships.

C. I will avoid giving or receiving gifts or entertainment if there is likelihood that they may be intended to improperly influence my judgment in dealing with or for UCS, and/or if it presents a real or perceived conflict of interest or boundary violation. The term gift, as used here, includes, but is not limited to, cash, goods, entertainment, services, loans, trips, or the use of property. I will notify my manager of any gifts offered to or received by me.

D. I will make no payment, gift or favor to any person in a position of trust in order to violate their duty or to obtain favorable treatment in negotiations or the award of contracts.

E. I will avoid any situation or action that may create or appear to create a conflict of interest with clients, staff, vendors or the community in general.

F. I will, upon termination of my employment for any reason whatsoever, immediately return to UCS all property, inventions, writings, files, memoranda and documents, electronic or otherwise, that are in my possession or are under my control as a result of my employment with UCS. I will also remove work related content from my personal telecommunication and/or other electronic devices.

G. I realize that any violation of ethical or legal standards will damage relationships and tarnish the reputation of UCS. As such, I will adhere to all such standards and will encourage and support my fellow employees to do likewise. Should I have a question about a conflict of interest or become aware of any violation of ethical or legal standards, I will immediately seek guidance for my question or report the violation to the UCS Compliance Officer.

H. I understand that professional boards and accrediting bodies have ethical practice standards for which I may also be accountable. I will strive to abide by the standards of and maintain good standing with these organizations during my employment at UCS, particularly knowing that my actions may impact UCS clients and/or the agency as a whole.

IV. RESPONSIBILITY TOWARD ORGANIZATION

A. I recognize the necessity of adhering to the policies, procedures, and ethical standards of UCS and agree and commit to do so. Towards that end, I have reviewed and agree to comply with the UCS Personnel Policies and Procedures, particularly those set out in Section VIII Administration, Section IX Health Safety and Security, Section X Compliance, Section XI Management Information Systems and the Social Media Policy.

B. I have the responsibility to promote the most positive reputation possible through our relationships with individuals and the community. In this regard, I understand that spreading rumors, gossiping, or making disparaging comments about UCS, its employees, and clients does not advance the reputation of UCS.

C. I will accurately represent myself (education, license/certification, training, experience, and competencies), treatment techniques and the mental health and developmental service professions at all times. Should others misrepresent my credentials, qualifications or other information about me, I will take immediate and appropriate action to have this misrepresentation corrected.

D. I will represent UCS and the services it provides in a straightforward and honest manner.

E. I understand and agree that all ideas, inventions, discoveries and improvements whether written, drawn, photographed, recorded or otherwise produced, whether or not capable of being patented, trademarked or copyrighted, made, devised or discovered in connection with my employment and the services that I render are the sole property of United Community Services.

F. I will not utilize UCS resources for non-UCS purposes or transact other than UCS business during working hours.

G. I will not participate in any lobbying efforts during working hours unless I receive specific permission to do so from the UCS Executive Director.

H. I understand that I am not to make any political contributions on behalf of UCS. Any political contributions that I do make are strictly made on a personal level.

I. I will act in an ethical and professional manner when representing UCS regardless of circumstances.

J. I will maintain a respectful relationship with all co-workers, support their efforts to reach their full potential as a professional, and promote a healthy and collaborative working environment.

K. I will strive to maintain professional behavior and demeanor in all situations. If my behavior is other than professional, I will remove myself from the situation if possible, or will respond cooperatively if I need to be removed from the situation.

L. I have reviewed and will comply with my Division’s Operations Manual.

M. I have reviewed and will comply with the UCS Information Technology (IT) Guidelines and understand that they define the boundaries of “acceptable use” of electronic resources inclusive of but not limited to social media, electronic communications, matters pertaining to privacy and security, system access and overall best practice.

N. I will strive to uphold the standards associated with Centers of Excellence that promote UCS as a “great place to work and great place to get care.”

O. I will uphold the agency’s “I CARE” customer services values and hold my colleagues accountable to that same standard.

V. CONFIDENTIALITY

A. I will abide by all federal and state laws, as well as UCS rules and regulations regarding confidentiality. I understand that I am prohibited from releasing or revealing any information, electronic, written or oral, about clients without their or their guardian’s expressed written authorization. I understand that these rules and regulations, as described in the UCS “Notice of Privacy Practices”, and/or the agency’s policies and procedures regarding confidentiality and release of information, apply to all programs and activities including, but not limited to, treatment, training, rehabilitation, administration, education, and finance. Records and information covered by confidentiality rules and regulations include, but are not limited to, client’s identification and status records and information, diagnostic records and information, prognostic records and information, treatment, training, and rehabilitation records and information, attendance records and information, and payer and fee records and information.

B. I understand that there are certain instances where information may be disclosed without the authorization of the client. I have reviewed and will comply with Section X, Division N of the UCS Personnel Policies and Procedures which sets out requirements related to the Disclosure of Protected Health Information to Others Involved in an Individual’s Care. If I am required to disclose information I will do so in a respectful manner adhering to the client’s legal and human rights and will follow all UCS policies and procedures relating to the release of information, including those set out in Section VIII Administration and Section X Compliance of the UCS Personnel Policies and Procedures. Instances where I may be required to share information are as follows:

1. When there is a bona fide medical emergency, information may be given to medical personnel.
2. When disclosure will prevent or lessen a serious and imminent threat to the health or safety of a person or the public; such as a “duty to warn”.
3. When authorized by a court order, information may be released. Such an order would release the disclosure prohibitions but could not, of its own force, require disclosure.
4. When communication of information does not constitute disclosure, i.e.:
Those that do not identify the client in any way;Those within UCS that are between staff having a need for such information in connection with their duties or in the case of an emergency;

• Those that do not identify the client in any way;
• Those within UCS that are between staff having a need for such information in connection with their duties or in the case of an emergency;
• Those between a program and a qualified service organization. A “qualified service organization” is a person or organization that provides services to a program such as data processing, bill collecting, laboratory analysis, or legal, medical, accounting, or other professional services, or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual group therapy. (42 CFR Part 2) To be qualified as a “qualified service organization” it must agree by signing a “Business Associate Agreement” and be bound by these regulations.

C. I will follow UCS policies and procedures when storing or disposing records or other information about clients.

D. I will refer all media inquiries and other inquiries of a general nature to the Executive Director or his or her designee. The Executive Director must approve all press releases, publications, speeches, or other official declarations by designated personnel in advance.

E. I will refer inquiries seeking information concerning applicants for employment, current employees, or former employees to the Director of Human Resources, who will identify the reason for the inquiry prior to releasing any information. This includes all requests for references. I have reviewed and will comply with Section VII Division D References of the UCS Personnel Policies and Procedures.

F. I understand that my responsibility for maintaining confidentiality is not limited to clients but also includes colleagues and any proprietary information pertaining to UCS.

G. I will ensure that all of my communication, whether verbal or written, will be conducted in an appropriate and discreet manner thereby ensuring that information and identification regarding clients is protected.

H. I will not use or disclose to anyone not affiliated with United Community Services or its affiliates or subsidiaries any confidential or unpublished information that I may obtain as a result of my employment.

I. I will abide by all confidentiality and privacy laws, rules, regulations, policies and procedures both during my employment with UCS and for all time following termination of my employment with UCS.

VI. DISTRIBUTION AND ENFORCEMENT

A. I understand that should I become aware of or suspect a violation of this Standard of Ethical and Professional Behavior that it is my responsibility to report the matter promptly to my Division Director or to the Director of Human Resources.

B. I understand that if I am the initial point of contact for a client, it is my responsibility to advise on any standards of professional conduct as required by my program or credentialed profession as applicable.

C. I understand that on an annual basis I will be required to confirm my compliance and understanding of this standard, inclusive of HIPAA privacy regulations.

D. I understand that the Director of Human Resources may present any significant suspected violations to the Peer Review Committee. The Peer Review Committee, comprised of the Executive Director, the Medical Director, the Director of Human Resources, and a Division Director (from an area not involved with the suspected violation) and the Chairperson of the Incident Risk and Review Committee, will assess compliance and issue recommendations to the Human Resources department for final action. Violations of this code may be cause for prompt and appropriate disciplinary action, up to and including termination and possible legal action.

E. I understand that the Peer Review Committee will provide a forum to review various issues relating to ethical practices to assist in determining the appropriate response to issues arising through the interaction with the community and UCS’ employees.

F. I understand that this standard applies to United Community Services, its subsidiaries and affiliates. It may be appropriate that any division adapt this code to meet their specific needs. Any adaptation will be in conjunction with this standard. In such circumstances, it would be the duty of the appropriate Division Director to alert the executive director and the Director of Human Resources of such special circumstances.

G. I will, if uncertain as to the interpretation of this Standard of Ethical and Professional Behavior, seek advice from my immediate supervisor, Division Director, or the Director of Human Resources

PURPOSE:  To establish a formal mechanism for soliciting and responding to complaints, grievances and/or appeals on the part of clients or other interested parties, to utilize such information in the quality improvement efforts of the organization and to ensure compliance with the Vermont Agency of Human Services (AHS) Grievance and Appeals process.

POLICY:  It is the policy of United Community Services that any grievance or appeal regarding services and/or support raised by a client, parent, family member, guardian, or a person acting on behalf of the client, who does so with his/her express permission, will be given due consideration.

DEFINITIONS (as defined by the Medicaid Program Grievance and Appeals manual):

An action is  an occurrence of one or more of the following by United Counseling Service (UCS) for which an internal appeal may be requested.

a.) Adverse Benefit Determination means any of the following:

• Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements of medical necessity, appropriateness, setting, or effectiveness of a covered service,
• Reduction, suspension, or termination of a previously authorized service,
• Denial, in whole or in part, of payment for a service,
• Failure to provide services in a timely manner, as defined by the Agency of Human Services,
• Failure to act within timeframes regarding standard resolution of grievances and appeals,
• Denial of a beneficiary’s request to obtain services outside of a network,
• Denial of a beneficiary’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other beneficiary liabilities

b.) Internal Appeal is a request for an internal review of an action by United Counseling Service (UCS) of an adverse benefit determination.

c.) Designated Agency/Specialized Service Agency (DA/SSA) means an agency designated or deemed by the Department of Mental Health or the Department of Disabilities, Aging and Independent Living to provide and administer services, including services authorization decisions, for beneficiaries with mental health needs and/or developmental disabilities.

d.) ACO means Accountable Care Organization

e.) Authorized Representative means an individual, either appointed by a member or authorized under state or other applicable law, to act on behalf of the member in obtaining a determination or in dealing with any of the levels of the appeal or grievance process. Unless otherwise stated in the rule, the designated representative has all of the rights and responsibilities of a member in obtaining a determination or in dealing with any of the levels of the appeals process.

f.) Expedited Internal Appeal means an appeal in an emergent situation in which taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.

g.) Fair Hearing means an external appeal that is filed with the Human Services Board, and whose procedures are specified in rules separate from the UCS process.

h.) Grievance is an expression of dissatisfaction about any matter that is not an adverse benefit determination, including a member’s right to dispute an extension of time proposed by UCS and the denial of a request for an expedited appeal. Possible subjects for grievance include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member’s rights. If a grievance is not acted upon within the timeframes specified, the member may ask for a fair hearing under the definition above of an action as being “failure to act in a timely manner when required by state rule.”

i.) Medicaid Program means (1) DVHA in its managed care function of administering services, including service authorization decisions, under the Global Commitment to Health Waiver (“the Waiver”), (2) a State department of AHS (i.e., Department of Children and Families; Department of Disabilities, Aging, and Independent Living; Department of Health; and Department of Mental Health) with which DVHA enters into an agreement delegating its managed care functions including providing and administering services such as service authorization decisions, under the Waiver, (3) a Designated Agency or a Specialized Service Agency to the extent that it carries out managed care functions under the Waiver, including providing and administering services such as service authorization decisions, based upon an agreement with a State department of AHS, and (4) any subcontractor performing service authorization decisions on behalf of a State department of AHS.

j.) Network means the providers who are enrolled in the Vermont Medicaid program and who provide services on an ongoing basis to beneficiaries.

k.) Provider means a person, facility, institution, partnership, or corporation licensed, certified or authorized by law to provide services to a beneficiary.

l.) Service means a benefit (1) covered under the Global Commitment to Health Waiver, (2) included in the State Medicaid Plan, (3) authorized by state rule or other law, (4) required by federal law, or (5) identified in the Intergovernmental Agreement between DVHA and AHS for the administration and operation of the Global Commitment to Health Waiver.

AHS Departments:  Department of Mental Health (DMH); Department of Disabilities, Aging and Independent Living (DAIL); Division of Disability and Aging Services (DDAS); Department of Health, Division of Alcohol and Substance Abuse (ADAP); Department of Health, Vision of Children with Special Needs (CSHN), Department of Vermont Health Access (OVHA).

Notices of full state procedures can be found in the Grievance and Appeal Manuals published by:  DMH for mental health programs; DAIL for developmental services and ADAP for substance abuse programs.  The Grievance and Appeals Coordinator will provide copies upon request.

PROCEDURE:  A person receiving or participating in services and/or programs will be oriented to, and receive a copy of, the Agency’s Grievance & Appeal policy and procedure upon enrollment in a program.

A grievance may be expressed orally or in writing. A member or designated representative may file a grievance at any time. Staff members will assist a member if the member or his representative requests such assistance. This includes but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have TTY/TDD and interpreter capability. Clients or their representatives (i.e., a person receiving services, their family member, or other person acting on their behalf) do not have to request a written response from the agency to have their concern addressed as a formal grievance.

Members may grieve a matter that is not an adverse benefit determination including denial of a request for an expedited appeal, an extension of time by UCS for decision of a service authorization or resolving an internal appeal, quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, and the failure to respect a beneficiary’s rights.

The agency will not require that grievances be put in writing before considering them formal grievances. The agency will make forms available for this purpose, but the member is not required to complete the form. Agency staff members will assist a member if the member or their representative requests assistance in filing a grievance. UCS will train staff in the practices and procedures to promote prompt informal and formal resolution of disagreements.

A person receiving services, their family member, or other person acting on their behalf, having a grievance or appeal shall be offered a Grievance and Appeal Form to complete and/or explain the grievance or appeal to the person’s primary UCS therapist, case manager or service provider who will assist with, or complete, the Grievance and Appeal Form.  The primary therapist/case manager/service provider shall report the grievance or appeal to the UCS Grievance and Appeals Coordinator, either directly or through the related Division Director, using the Grievance and Appeal Form.  The original form will be forwarded to the Grievance and Appeal Coordinator.  The Division Director will work with the Grievance and Appeal Coordinator to review/investigate all grievances and appeals from the initial filing through resolution.

UCS shall provide the member, free of charge, with all the information in its possession or control relevant to the grievance process and the subjects of the grievance, including the members case record, including medical records and other records and documents related to the grievance, and other information relevant to members grievance including relevant policies and procedures.

Alleged Harm:  If a grievance is composed of a clear report of alleged physical harm or potential harm, UCS will immediately investigate or refer to the appropriate investigatory body (fraud, malpractice, professional regulation board, Adult Protective Services, etc.).

Written Acknowledgment:  All grievances and appeals require a written acknowledgment to be sent to the client and/or the person filing the grievance or appeal within five (5) calendar days of receipt of the grievance or appeal.  If the issue is resolved within five days, the resolution or outcome notice will be sufficient and no written acknowledgment will be required. All UCS grievances and appeals will be logged into the Department of Vermont Health Access’s (DVHA) Grievance and Appeal database.  UCS Complaints will be logged into an in-house database.

Withdrawal of Grievances: Members or their designated representatives may withdraw grievances orally or in writing at any time. If a grievance is withdrawn orally, the withdrawal will be acknowledged by UCS in writing within five (5) days.

Disposition:  All grievances shall be addressed within 30 days of receipt.  The UCS Grievance and Appeals Coordinator must provide the member with written notice of the disposition.  The written notice shall include a brief summary of the grievance, the basis or rationale for the decision in sufficient detail for the member to understand the decision, and the disposition.  If the response is adverse to the member, the notice must also inform the member of his or her right to initiate a grievance review with the State as well as information on how to initiate such review. If UCS does not act upon the grievance within the timeframe for the resolution, the member may request an internal appeal pursuant to the definition of adverse benefit determination. 

Appeal Procedures:

 a.) Filing of Appeals: Members may file appeals orally or in writing for any adverse benefit determination. There is no right to appeal matters where a federal or state law requiring change has adversely affected some or all members. Providers and representatives of the member may initiate appeals only after a clear determination that the third party’s involvement is being initiated at the member’s request, except that providers may not request the services be continued pending appeal. Appeals of adverse benefit determination must be filed with UCS within sixty (60) days of the date the agency’s notice of adverse benefit determination. The parties to an internal appeal are the beneficiary or their representative, or the legal representative of a deceased beneficiary’s estate. UCS will give members reasonable assistance in completing forms or other steps to initiate and participate in the internal appeals process. Assistance auxiliary aids and services upon request as also noted above. Members may also contact the Office of Health Care Advocate at 1-800-917-7787 for help with this process or decision making about the process.

b.) Written Acknowledgement of the appeal shall be mailed within five (5) days of receipt of appeal by the agency.

c.) Withdrawal of Appeals may be done orally or in writing at any time by members or their representatives.

d.) Member Participation in Appeals: The member, their authorized representative, or their provider, if requested by the provider has the right to participate in person, by phone, or in writing in the meeting in which UCS is considering the issue that is the subject of the appeal. This may include the right to present evidence, testimony and legal arguments. Upon request and prior to the appeal meeting, the agency shall provide timely copies of information relevant to the appeals process and the subject of the appeal, at no cost to the member. UCS shall inform the member of the scheduled appeal meeting and reschedule to accommodate individuals wishing to participate. If a meeting cannot be scheduled within the timeframe for resolving the appeal, the agency may make a decision that resolves the appeal without a meeting with the member, or their representatives.

e.) Appeals Reviewer: The UCS staff member responsible for hearing the appeal shall not have been involved in any previous level of review or decision making, not be a subordinate of any such individual, and shall have appropriate clinical expertise of member conditions or illness when deciding an appeal of a denial of medical necessity.

Resolution: UCS shall act promptly and in good faith to obtain necessary information to resolve the appeal. The internal review shall be completed, appeals shall be decided, and written notice sent to the member within thirty (30) days of receipt of the appeal. The individual/representative or UCS may request an extension of up to 14 days if that extra time is in the best interests of the individual.  The maximum total time period for the resolution of an appeals, including any extension requested either by the member or the Medicaid Program, is 44 days. If a meeting cannot be scheduled within these timeframes, a decision will be rendered by the Medicaid Program without a meeting with the member, the designated representative, or treating provider.

Expedited Internal Appeals Request:  Expedited appeals may be requested in emergent situations in which the member or the treating provider (in making the request on the member’s behalf or supporting the member’s request) indicates that taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.  Requests for expedited internal appeals may be made orally or in writing with the Medicaid Program for any adverse benefit determination subject to appeal. No punitive action may be made against a provider who requests or supports an expedited resolution.

If the request for an expedited appeal is denied because it does not meet the criteria, the Medicaid Program will inform the member that the request does not meet the criteria for expedited resolution and that the appeal will be processed within the standard 30 -day time frame. An oral notice of the denial of the request for an expedited appeal must be promptly communicated (within 2 days) to the member and followed up within 2 days of the oral notification with a written notice.

If the expedited appeal request meets the criteria for such appeals, it must be resolved within 72 hours.  If an expedited appeal cannot be resolved within 72 hours, the time frame may be extended up to an additional 14 days by request of the member, or by the Medicaid Program if the extension is in the best interest of the member.  If the extension is at the request of the Medicaid Program, it must give the member written notice of the reason for the delay.  An oral notice of the expedited appeal decision must be promptly communicated (within 2 days) to the member and followed up within 2 days of the oral notification with a written notice.  The written notice for any expedited appeal determination shall include a brief summary of the appeal, the resolution, the basis for the resolution, and the member’s right to request a fair hearing if not already requested.

Finally, clients shall be advised of their right to representation or the assistance of an advocate at any stage of the grievance and appeal procedure.  They will also be assured of the confidentiality of the proceedings and that no retribution of any kind will result from filing a grievance or an appeal.

Fair Hearing: This is a process whereby the individual/representative making an appeal and UCS, working with DMH and the DMH Legal Unit, each presents their side of the situation to the Human Services Board.  A request for fair hearing by the Human Services Board (HSB) must be filed no later than 30 days after receipt of the adverse appeal decision or within 90 days of the original action.

Complaint Procedures of Other State or Federal Programs: Additional processes shall be followed as outlined by state or federal bodies not specified in this policy but whose regulations require a specific complaint procedure. When applicable to a UCS program, such details will be included in the division Operations Manual; an example being the Civil Rights Requirements in Child Nutrition Programs as governed by the Vermont Agency of Education and the U.S. Department of Agriculture.

Download UCS Grievance & Appeal Form