PAS Grievance

1. G18 – CHC Grievance General Scheduling Notice MA
CHC GENRL SCHED NTCE MA 20CHC1222300
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UPMC HEALTH PLAN
MEMORANDUM
TO: Grievance Review Committee
FROM: Coordinator, Complaints and Grievances
DATE: 12/08/2022
SUBJECT: Grievance
Enclosed you will find information regarding the Grievance Review for our
member MAXIMILIAN GRAVENSTEIN. The review will be held on 12/21/2022
11:00. The review will be held in Camp Hill, PA.

2. G18 – CHC Grievance General Scheduling Notice MA
CHC GENRL SCHED NTCE MA 20CHC1222300
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GRIEVANCE COMMITTEE REVIEW
MAXIMILIAN GRAVENSTEIN
12/21/2022 11:00
AGENDA
1. Introductions UPMC Health Plan
2. Committee structure, rules and process UPMC Health Plan
3. Summary of Information UPMC Health Plan
4. Member and/or representative (if present) presents Member
to committee
5. Member may question information presented Member
6. Committee members may question member Committee
7. Committee makes decision Committee
8. Adjournment

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CHC GENRL SCHED NTCE MA 20CHC1222300
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Grievance Review Structure, Rules, and Process
1. The Committee is made up of three or more people, including at least one person
who is not an employee of UPMC Community HealthChoices, and who have not
been involved in the issue you filed your Grievance about.
2. An informal hearing will be held within 30 days of the receipt of the request for the
Grievance.
3. UPMC Health Plan may take minutes, a tape recording, and/or a verbatim
transcript of the meeting. This is done to ensure an adequate record of the
hearing is established.
4. The Committee member’s responsibility is to impartially hear and consider the
dispute based on the material and presentations made during the hearing.
5. The member, if present, is introduced to the Committee.
6. The members of the Committee are introduced.
7. The Coordinator of Grievances will:
 summarize the Grievance and prior actions taken, and
 give the Health Plan’s reason for continued denial of the Grievance.
8. The Committee may question the information presented by the Coordinator.
9. The Member will then present to the Committee.
10.The Member may question the information presented by the Coordinator.
11.The Committee may ask questions of the Member.
12.After both the Member and the Committee present their case, the Member, if
present, will then leave the meeting before the Committee makes a decision.
13.The Committee will make a decision and send the Member its written resolution
within five (5) working days of the hearing.
The Member has the right to:
1. Appear at the hearing and present their views on the Grievance although not
required to attend.
2. Participate in the hearing by other means if unable to attend in person – i.e.,
conference call.
3. Submit additional written comments or documentation regarding the case.
4. Bring persons who may clarify the Grievance.
5. Have an interpreter present.
6. Receive a copy of the material furnished to the Committee.
7. Assistance of an impartial member of the Health Plan staff to assist in presenting
or preparing the case to the Committee.

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8. Have an attorney come and represent them at the hearing. Please tell UPMC
Community HealthChoices as far in advance as possible that you plan to bring
legal representation so that the committee may also have a lawyer present. This
is an informal hearing with no formal rights of examination and cross-
examination.
Member Notification:
1. Formal decision in writing within five (5) working days of the hearing.
2. The notification will communicate that the decision is binding unless the Member
appeals the decision to the appropriate next level.
3. The written notice will contain:
 A statement of the issue reviewed by the Review Committee.
 The specific reason or reasons for the decision.
 References to the specific plan provisions on which the decision is based.
 An explanation of the next level of appeal.

5. G18 – CHC Grievance General Scheduling Notice MA
CHC GENRL SCHED NTCE MA 20CHC1222300
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Grievance Summary Form
UPMC Health Plan
Type: Grievance
Product: JCH01-UPMC CHC W/LTSS
Unique Identifier: A22332393518
Nature of Dispute: LTSS Medical Necessity/Personal assistance services
Services
Resolution: In Progress
Grievance Summary
Participant’s Position: Participant is appealing the denial received for PAS hours (an
initial 168 hours per week of Personal Assistance Services (PAS)).
Continuation of Care not applicable.
The Reasons for UPMC’s Decision are as Follows: Your request was not approved
as requested because your assessment does not support a need for 168 hours per
week of PAS. Your assessment, done in your home, supports 112 PAS hours to
meet your needs. These hours will help with Meal Preparation, Housework,
Managing Finances and Medications, Phone Use, Shopping, Stairs, Transportation,
Bathing, Hygiene, Dressing, Toilet Use, Toilet Transfer, Bed Mobility, and Eating.
This will be listed in your service plan. You will get a copy of your service plan with
all approved services. Your service coordinator will continue to work with you and
your person-centered planning team to ensure your needs are met.
SUMMARY OF CASE
11/15/2022– A UPMC Community HealthChoices Service Coordinator completed a
telephonic and in-person assessment. The requested 168 hours per week of
personal attendant services are approved as other than requested: 112 hours per
week are approved, 56 hours per week are denied.
Rationale: Based on the in person and telephonic assessment by the service
coordinator, 112 hours per week are sufficient to meet your personal care needs.
Service coordinator completed an Initial assessment with participant both in person
and over the phone. The participant did not need an interpreter or interpreter
services. The participant lives alone. His home is in good condition. He does not
currently have any personal assistance services in place due to being new to LTSS.
His mother/ chosen personal representative Jane Gravenstine is able to provide
back up support if needed. Participant will utilize outside caregivers from agencies.
He does not have any informal supports. The participant reported utilizing a power
chair, which was observed during the face-to-face visit. Participant does not utilize

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any incontinence supplies however he does have a leg bag that collects urine.
Participant states he doesn't have any new diagnoses, current diagnoses have been
documented in the Interrai. There are no concerns with the participants cognitive,
moods and behaviors. Participants medications have been reviewed and added to
plan; participant is new to LTSS and does not have a completed Person-Centered
Service Plan. Due to being new to LTSS he has had no appeals in the last 12
months and no Critical Incidents in the past 90 days. The participant has not fallen in
the past 90 days. Participant has a safety score of 9. Participant has requested 24/7
care because he states he cannot ever be left alone due to the severity of his case
and not having any movement in his body. Supervision is not a covered benefit. The
participant is able to assist with the following: Managing Finances: Maximilian is able
to pay bills, budget and balance his checkbook/ bank account electronically by using
voice command with his computer. Managing Medications: Maximilian remembers
when to take his medications, he understands the correct dosages. Managing
Medications: Maximilian is able to navigate his phone if it is in his hand. Locomotion:
Maximilian is able to move his power chair from Point A to Point B however he
requires a caregiver to be with him at all times. Eating: Maximilian has a robot that
will feed him however he is dependent on his caregiver to fill up the containers.
Service coordinator offered a personal emergency response button however
participant declined as he is unable to press the button. Service coordinator offered
non-medical transportation; participant has accepted. Service coordinator offered the
Medical Assistance Transportation Program number to apply for Medical
Transportation in his area of living, he declined stating he will be going back to
Philadelphia for doctors' appointments. Service coordinator offered a behavioral
health referral, participant declined as behavioral mental health is not a concern at
this time. A referral for benefits counseling will be made as participant is employed.
Participant has requested 168 hours a week of caregiving because he states he
cannot move and is 100 percent dependent on other people for everything, he states
being left alone is a huge safety risk and his needs won't be met. Approved PAS
hours of 112 are sufficient in meeting the participant's needs based on the
assessment. Per the list of recommended approved tasks, it is believed Participants
ADL and IADL needs can be met with 112 hours per week.
11/16/2022- UPMC Community HealthChoices sent denial letter to the participant.
11/16/2022- UPMC Community HealthChoices outreached to the participant to notify
of the denial and appeal process.
11/25/2022– UPMC Community HealthChoices received a grievance.
11/29/2022- UPMC Community HealthChoices issued a letter to the participant
acknowledging receipt of grievance.
12/08/2022 – UPMC Community HealthChoices issued a hearing packet containing
a scheduling notice to the participant with the date and time of the hearing to review
the grievance on 12/21/2022 at 11:00 A.M.

7. CHC PARTIAL APPROVAL LTR N2 UM 20CHC1199233
[LTR-BD]
11/16/2022
MAXIMILIAN GRAVENSTEIN
17 S 2ND ST APT 103
HARRISBURG, PA 17101-2006
RE: MAXIMILIAN GRAVENSTEIN DOB: 02/11/1998
Dear MAXIMILIAN GRAVENSTEIN:
This is an important notice about your services. Read it carefully.
Call UPMC Community HealthChoices at 1-844-833-0523 (TTY: 711) if you have any
questions or need help. Representatives are available 24 hours a day, 7 days a week.
UPMC Community HealthChoices has reviewed the request for an initial 168 hours per week
of Personal Assistance Services (PAS) submitted by your Service Coordinator, Jillian Forscht,
for you on 11/15/2022. After physician review, the request is:
Approved other than as requested as follows:
 112 hours per week of PAS are approved for your service plan.
 56 hours per week of PAS are denied.
Your request was not approved as requested because your assessment does not support a
need for 168 hours per week of PAS. Your assessment, done in your home, supports 112 PAS
hours to meet your needs. These hours will help with Meal Preparation, Housework, Managing
Finances and Medications, Phone Use, Shopping, Stairs, Transportation, Bathing, Hygiene,
Dressing, Toilet Use, Toilet Transfer, Bed Mobility, and Eating. This will be listed in your
service plan. You will get a copy of your service plan with all approved services. Your service
coordinator will continue to work with you and your person-centered planning team to ensure
your needs are met.
What if I disagree with the decision to deny my request for services?
 You may file a Complaint or Grievance with UPMC Community HealthChoices by
01/15/2023.

8. CHC PARTIAL APPROVAL LTR N2 UM 20CHC1199233
[LTR-BD]
 You may ask for the medical necessity guidelines or other rules UPMC Community
HealthChoices used to make this decision, at no cost to you. To ask for a copy of the
medical necessity guidelines or other rules that UPMC Community HealthChoices used to
make the decision, call UPMC Community HealthChoices at 1-844-833-0523 (TTY: 711) or
write a letter. Representatives are available 24 hours a day, 7 days a week. If you file a
Complaint or Grievance, you can ask for a copy of this information by checking Box 3 on
the “Complaint/Grievance Request Form.”
• You may get a second opinion from another provider in UPMC Community HealthChoices
network. Call UPMC Community HealthChoices at 1-844-833-0523 (TTY: 711) to get a
referral for a second opinion. Asking for a second opinion will not give you more time to file
a Complaint or Grievance. It will not continue any service or item that you have been
getting.
How do I file a Complaint or Grievance?
You can file a Complaint or Grievance by phone, by using the “Complaint/Grievance Request
Form,” or by writing a letter.
To file a Complaint or Grievance:
By Phone: Call UPMC Community HealthChoices at 1-844-833-0523. TTY users should
call 711.
By Fax: Fax the “Complaint/Grievance Request Form” or a letter to 412-454-7920; or
By Mail: Mail the “Complaint/Grievance Request Form” or a letter to the following
address:
UPMC Community HealthChoices
Complaints, Grievances, and Appeals
P.O. Box 2939
Pittsburgh, PA 15230-2939
How long will it take to decide my Complaint or Grievance?
UPMC Community HealthChoices will send you a written notice of the decision on your
Complaint or Grievance within 30 days from when UPMC Community HealthChoices received
your Complaint or Grievance.
How do I ask for an early decision on my Complaint or Grievance?
If you or your doctor or dentist thinks waiting 30 days for a decision could harm your health,
call UPMC Community HealthChoices at 1-844-833-0523 (TTY: 711) to ask for an early
decision on your Complaint or Grievance.
You should also ask your doctor or dentist to fax a signed letter to 412-454-7920 within 72
hours of when you asked for an early decision on your Complaint or Grievance. The letter
should explain why waiting 30 days for a decision could harm your health.
UPMC Community HealthChoices will tell you the decision within 48 hours from when UPMC
Community HealthChoices gets your doctor’s letter, or within 72 hours from when you asked
UPMC Community HealthChoices for an early decision, whichever is sooner, unless you ask

9. CHC PARTIAL APPROVAL LTR N2 UM 20CHC1199233
[LTR-BD]
UPMC Community HealthChoices to take more time to decide your Complaint or Grievance.
You can ask UPMC Community HealthChoices to take up to 14 more days to decide your
Complaint or Grievance.
What happens after I file my Complaint or Grievance?
UPMC Community HealthChoices will hold a meeting within 30 days of when you filed your
Complaint or Grievance to review your Complaint or Grievance. You may attend the meeting
either in person, by phone, or by videoconference. You may also bring a family member,
friend, or lawyer to help you during the meeting.
How can I get help with my Complaint or Grievance?
If you need help filing a Complaint or Grievance, you can call UPMC Community
HealthChoices at 1-844-833-0523 (TTY: 711). Representatives are available 24 hours a day, 7
days a week.
To ask for free legal help with your Complaint or Grievance, contact:
 Pennsylvania Health Law Project at 1-800-274-3258 (www.phlp.org); or
 Pennsylvania Legal Aid Network at 1-800-322-7572 (www.palegalaid.net)
Sincerely,
UPMC Community HealthChoices
cc:

10. Participant Statement
11/25/2022
I was given the 112 and i am trying to get 168 for 24/7 care. I have Monday 7am to Friday 7pm and it
doesn't allow me to stay in my apartment over the weekend and my parents would have to come get
me and take me back to Philly. I am wanting 24/7 care because i am trying to be independent and that
means not depending on my parents for support.

11. 1. Participant Last Name GRAVENSTEIN
2. Participant First Name MAXIMILIAN
3. Participant DOB 02/11/1998
4. Member # 01767021101
5. Best contact number (the most correct number for the Participant is needed so that UM can make the
verbal notification timely and more successfully) 352-519-7901
6. PCP Name Robinson, Laura
6a. PCP Phone 215-662-2250
7. Current Diagnoses (List all current diagnoses from the most recent assessment)
Duchenne Muscular Dystrophy, Cardiomyopathy, Sleep Apnea
8. How was the assessment conducted?
In person and telephonic
9. Service Coordination Summary: Service(s) requested
Personal Assistance Services (hours per week)
10. Is the service currently authorized on the service plan?
No
12.a What is being requested by the Participant related to this recommended denial
New to LTSS - Requested increase in initial assessment of PAS
Adverse Determination Summary
15.a Enter the amount of the service requested 168
15.b Enter the amount of the service recommended approved 112
16. The amount of the service recommended denied 56

12. 17. Rationale for adverse determination (select ALL that apply)
Participant is requesting activities that are not a part of the PAS benefit (Ex. Lawn care, snow shoveling,
pet care, childcare, companionship, etc.)
18. Please provide a brief summary, including observation, to support the adverse determination
rationale selections chosen in #17
Service coordinator completed an Initial assessment with participant both in person and over the phone.
The participant did not need an interpreter or interpreter services. The participant lives alone. His home
is in good condition. He does not currently have any personal assistance services in place due to being
new to LTSS. His mother/ chosen personal representative Jane Gravenstine is able to provide back up
support if needed. Participant will utilize outside caregivers from agencies. He does not have any
informal supports. The participant reported utilizing a power chair, which was observed during the face-
to-face visit. Participant does not utilize any incontinence supplies however he does have a leg bag that
collects urine. Participant states he doesn't have any new diagnoses, current diagnoses have been
documented in the Interrai. There are no concerns with the participants cognitive, moods and
behaviors. Participants medications have been reviewed and added to plan; participant is new to LTSS
and does not have a completed Person-Centered Service Plan. Due to being new to LTSS he has had no
appeals in the last 12 months and no Critical Incidents in the past 90 days. The participant has not fallen
in the past 90 days. Participant has a safety score of 9. Participant has requested 24/7 care because he
states he cannot ever be left alone due to the severity of his case and not having any movement in his
body. Supervision is not a covered benefit. The participant is able to assist with the following: Managing
Finances: Maximilian is able to pay bills, budget and balance his checkbook/ bank account electronically
by using voice command with his computer. Managing Medications: Maximilian remembers when to
take his medications, he understands the correct dosages. Managing Medications: Maximilian is able to
navigate his phone if it is in his hand. Locomotion: Maximilian is able to move his power chair from Point
A to Point B however he requires a caregiver to be with him at all times. Eating: Maximilian has a robot
that will feed him however he is dependent on his caregiver to fill up the containers. Service coordinator
offered a personal emergency response button however participant declined as he is unable to press the
button. Service coordinator offered non-medical transportation; participant has accepted. Service
coordinator offered the Medical Assistance Transportation Program number to apply for Medical
Transportation in his area of living, he declined stating he will be going back to Philadelphia for doctors'
appointments. Service coordinator offered a behavioral health referral, participant declined as
behavioral mental health is not a concern at this time. A referral for benefits counseling will be made as
participant is employed. Participant has requested 168 hours a week of caregiving because he states he
cannot move and is 100 percent dependent on other people for everything, he states being left alone is
a huge safety risk and his needs won't be met. Approved PAS hours of 112 are sufficient in meeting the
participant's needs based on the assessment.

13. 19. List the assessed ADLs and IADLs the person would be approved for based on this recommended
reduction
Meal Preparation, Ordinary Housework, Managing Finances, Managing Medications, Phone Use,
Shopping, Stairs, Transportation, Bathing, Personal Hygiene, Dressing Upper Body, Dressing Lower Body,
Locomotion, Toilet Use, Toilet Transfer, Bed Mobility and Eating
20. SC Name Jillian Forscht