What is an action?
An action is a denial, suspension, reduction, or termination of your services as defined below: • Denial: The decision by a PIHP not to authorize covered Medicaid mental health services that meet the Mental Health Division Access to Care Standards or the Medical Assistance Administration memorandum #01-03 MAA, Psychiatric Hospitalization. Or the decision by a PIHP not to authorize covered Medicaid mental health services due to lack of medical necessity. The decision by a Community Mental Health Agency not to provide a covered service is not a denial and can not be appealed. However, an enrollee who objects to a CMHA deciding not to provide a covered service may request a grievance or second opinion. • Suspension: The decision by a PIHP to temporarily stop an enrollee’s previously authorized covered Medicaid mental health services. The decision by a CMHA to temporarily stop a covered service is not a suspension. • Reduction: The decision by a PIHP to decrease an enrollee’s previously au
