DHS 10.52(3)(b)8. 8. The availability of independent advocacy services and other local organizations that might assist an applicant or enrollee with an appeal or fair hearing.

DHS 10.52(3)(b)9. 9. That the applicant or enrollee may obtain, free of charge, copies of client records relevant to the appeal or fair hearing, and how to obtain the copies.

DHS 10.52 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (b) 4. and (4) (a) and (e), cr. (3) (b) 5m. Register November 2004 No. 587, eff. 12-1-04; CR 22-026: am. (1) (intro.), (3) (intro.), (a) 2., (b) (intro.), 1., cr. (3) (b) 1m., am. (3) (b) 2. to 9., r. (4) Register May 2023 No. 809, eff. 6-1-23; correction in (3) (b) 8. made under s. 35.17, Stats., Register May 2023 No. 809.

DHS 10.53 DHS 10.53 Grievances and appeals.

DHS 10.53(1) (1) Grievance process in resource centers.

DHS 10.53(1)(a) (a) The governing board of each resource center shall approve and effectively operate a process for reviewing and resolving client grievances. The board may delegate, in writing, its responsibility for reviewing and resolving grievances to a committee of the resource center’s senior management, provided the process ensures that the board is made aware of grievances and requests for department review and fair hearings.

DHS 10.53(1)(b) (b) The department shall review and approve a resource center’s grievance process as part of its contracting with the resource center.

DHS 10.53(1)(c) (c) A resource center shall inform clients of all of the following:

DHS 10.53(1)(c)1. 1. The circumstances under which expedited resolution of a grievance is available and how to request it.

DHS 10.53(1)(c)2. 2. The client has the right to appear in person before the resource center personnel assigned to resolve a grievance filed, if the enrollee files the grievance.

DHS 10.53(1)(c)3. 3. The availability of independent advocacy services and other local organizations that might assist a client with a grievance.

DHS 10.53(1)(c)4. 4. The client may obtain, free of charge, copies of client records relevant to the grievance and how to obtain the copies.

DHS 10.53(1)(d) (d) A resource center shall assist individuals with the filing of grievances with the resource center.

DHS 10.53(1)(e) (e) A client may file a grievance with the resource center at any time.

DHS 10.53(1)(f) (f) The resource center shall complete its review of a grievance and issue its written decision to the client within 10 business days of its receipt of the grievance, unless the client and the resource center agree to an extension for a specified period of time.

DHS 10.53(1m) (1m) Appeals process in resource centers.

DHS 10.53(1m)(a) (a) Resource center adverse benefit determinations are appealed through the fair hearing process under s. DHS 10.55.

DHS 10.53(1m)(b) (b) A resource center shall assist clients with the filing of requests for fair hearings with the division of hearings and appeals.

DHS 10.53(2) (2) Grievance and appeals process in care management organizations.

DHS 10.53(2)(a) (a) The governing board of each CMO shall approve and shall effectively operate a process for reviewing and resolving enrollee grievances and appeals. The board may delegate, in writing, its responsibility for reviewing and resolving grievances and appeals to a committee of the CMO’s senior management, provided that the board is made aware of grievances and requests for department review and fair hearings.

DHS 10.53(2)(b) (b) The department shall review and approve a CMO’s grievance and appeal process as part of its contracting with the CMO.

DHS 10.53(2)(bg) (bg) An enrollee may file a grievance at any time.

DHS 10.53(2)(br) (br) The CMO shall complete its review of a grievance and issue its written decision to the enrollee within 90 days of its receipt of the grievance, unless the grievance decision timeframe is extended under the extension requirements specified in the contract with the department.

DHS 10.53(2)(c) (c) The CMO shall inform enrollees of all of the following:

DHS 10.53(2)(c)1. 1. The circumstances under which expedited resolution of a grievance is available and how to request it.

DHS 10.53(2)(c)2. 2. The enrollee has the right to appear in person before the CMO personnel assigned to resolve a grievance, if the enrollee files the grievance.

DHS 10.53(2)(c)3. 3. The availability of independent advocacy services and other local organizations that might assist an enrollee with a grievance.

DHS 10.53(2)(c)4. 4. The enrollee may obtain, free of charge, copies of enrollee records relevant to the grievance and how to obtain the copies.

DHS 10.53(2)(d) (d) A CMO shall assist enrollees with filing grievances with the CMO. If an enrollee is dissatisfied with the CMO’s grievance decision, or the CMO fails to render a grievance decision within the timeframe specified under par. (br), a CMO shall assist the individual with requesting a department review of the grievance under s. DHS 10.54.