Grievances


A Grievance is any expression of dissatisfaction, in person, orally, or in writing, of behavioral health service, other than an “Action”, by an individual or the individual’s authorized designated representative.

An Action is:

  1. The denial or limited authorization of a requested service, including the type or level of  service;
  2. The reduction, suspension, or termination of a previously authorized service;
  3. The denial in whole or in part, of payment for a service;
  4. The failure to provide services in a timely manner, as defined by the state; or
  5. The failure of a BHO or its contracted behavioral health agency to act within the grievance system.

How to File a Grievance

You or your authorized representative (such as: family member, friend, Ombuds) may file a grievance in person, orally, or in writing to the following:

  1. Your Network Provider for mental health and/or substance use disorder/chemical dependency services
  2. The Thurston-Mason Behavioral Health Organization (TMBHO)

360-867-2602 or 800-658-4105
412 Lilly Road NE Olympia WA 98506
Email: inquiries@tmbho.org

The written grievance should include the following:

  • Your name;
  • How to reach you;
  • The problem you have;
  • What you would like to have happen, if you know;
  • Your signature and date of signing.

Can the Ombuds Represent you in a Grievance?

With the appropriate signed releases, the Ombuds serving the Network Provider or TMBHO may assist you in resolving the grievance at the lowest possible level. You can reach the Ombuds at:

360-867-2556 or 800-658-4105
412 Lilly Road NE Olympia WA 98506
donna.kelly@tmbho.org

Review Process Timeline

When the Network Provider and/or TMBHO receives your grievance, they will let you know in writing within five (5) business days that the grievance has been received.

  1. Your grievance will be reviewed by people who have not been involved before with the issue(s). If your grievance is about behavioral health treatment, a qualified behavioral health care professional will be part of the review process.
  2. You will receive a letter from the Network Provider or TMBHO within 30 days of the receipt of the grievance
  3. If you filed a grievance at the Network Provider and are not satisfied with the decision, you may file it with TMBHO. You may contact TMBHO at:

360-867-2556 or 800-658-4105
412 Lilly Road NE Olympia WA 98506
merja.kehl@tmbho.org

What is an Adverse Benefit Determination?

A letter from TMBHO that denies, suspends, reduces, or terminates your Medicaid behavioral health services. This letter will contain:

  1. The denial of a Medicaid covered requested service, in whole or in part. The denial of requested medications is an Action only if you call the BHO and request this be treated as an Action.
  2. The reduction, suspension, or termination by the BHO of a previously authorized service. If your provider changes the amount or type of your services in a way you do not agree with, you can call the BHO to request this be treated as an Action.
  3. The failure of the BHO or provider to provide services to you in a timely manner.
  4. The failure of the BHO to act within the timeframes in the rules.

If you have questions about an Adverse Benefit Determination that you received from the TMBHO, please contact us at 360-867-2602 or 800-658-4105.

Ombuds Contact Information

An individual receiving services through Thurston-Mason BHO has the right to contact the Ombuds for assistance at any time. The Ombuds may be reached at:

360-867-2556 or 800-658-4105
412 Lilly Road NE Olympia WA 98506
theombuds@tmbho.org

For additional information about the Ombuds, please click here.

Administrative Hearing

If your Appeal is not resolved to your satisfaction by your network provider or TMBHO, you have the right to file an Administrative Hearing with the State.  If your TMBHO level grievance is resolved within the 90 day timeline as set forth in WAC, you have the right to file an Administrative Hearing with the State.

Administrative Hearings are filed with the Department of Social and Health Services (DSHS) Office of Administrative Hearings.

DSHS Office of Administrative Hearings
1-800-583-8271