Important Definitions

  • Affiliated CMHSP- (Community Mental Health Service Provider)- These are the places you go to for mental health services. At Southwest Michigan Behavioral health, this means Barry County Mental Health Authority ( Barry County), Pines Behavioral Health ( Branch County), Summit Pointe ( Calhoun County), Riverwood Center ( Berrien County), Van Buren Community Mental Health (Van Buren County), Woodlands Behavioral Healthcare Network (Cass County), Kalamazoo Community Mental Health and Substance Abuse Services(Kalamazoo County), and Community Mental Health & Substance Abuse Services of St. Joseph County (St. Joseph County).
  • Grievance – A formal way for you to tell us you are unhappy with service issues at the Community Mental Health Center you go to, or at Southwest Michigan Behavioral health, other than an “action”. (Examples would be: how you were treated by staff, what you thought of the agency’s office, if you have problems with your current caseworker, therapist, or doctor, as well as other things you are not happy with).
  • Authorization of Services- The process of Southwest Michigan Behavioral health and its affiliated CMHSP’s, when we decide whether or not you will receive a service based on medical necessity (as defined below).
  • Action (Adverse Action)- Is a decision that negatively impacts your ability to get a service, or the amount of the service you want, when you want it. It may also mean that Southwest Michigan Behavioral health or its affiliated CMHSP’s did not make a decision about what services you would receive, or did not begin to provide you the services you were authorized, within certain time frames.
  • Adequate Notice- Written notice telling you of a decision to deny or limit authorization of Medicaid services requested, which you are given at the time you request a service, or at the time of signing your Individual Plan of Services/Supports.
  • Advance Notice- Written notice telling you of a decision to reduce, suspend or terminate Medicaid services that are currently being provided to you. This notice will be mailed to you at least 12 days before your service is going to be effected.
  • Local Appeal – A formal request to Southwest Michigan Behavioral health and its affiliated CMHSP’s, to see if an “action” (as defined above) we have taken, should have happened.
  • ExpeditedAppeal- A review of an “action” done quickly if the “action” could cause serious life or health problems.
  • Recipient Rights Complaint- Written or verbal statement by you, or anyone acting on your behalf, alleging a violation of a Michigan Mental Health Code protected right.
  • Fair Hearing (Administrative Hearing) – A State of Michigan level review of your appeal of an “action” by a Michigan Department Of Community Health, Administrative Law Judge.
  • Member/customer- You. A person who has been determined to be eligible for Medicaid, and who is receiving, or may qualify to receive, Medicaid services through Southwest Michigan Behavioral health Behavioral Health and its affiliated CMHSP’s.
  • Developmentally Disabled (DD)- A condition that a person is either born with or occurs before they turn age 22. Persons with a developmental disability often need help in at least three of these areas:
    • Talking with or understanding others.
    • Learning new things.
    • Getting from place to place.
    • Making important decisions.
    • Living by themselves or with others without help.
  • Medical Necessity /Recovery – A term used to describe that the service that you want, is needed to help you. If a service is not going to help you it cannot be paid for.
  • Member Service Representative – A person you can call when you have questions or concerns at either your local provider site or Southwest Michigan Behavioral health.
  • PIHP – The Prepaid Inpatient Health Plan. Southwest Michigan Behavioral health is your PIHP and covers Calhoun, Branch, Berrien, Van Buren, Kalamazoo, St. Joseph, Cass and Barry counties. Southwest Michigan Behavioral health contracts with all the providers you may need in those five counties and makes sure that any covered service is conveniently available to you when you need it.
  • Person-Centered Planning – The services that you receive will be determined by what you want, what you need, who you want involved, where you want it to occur, when you want it to occur and by the person you choose at the time you and your provider agree on your care plan. You may change your care plan at any time.
  • Plan of Care – The plan that you develop with the people who you will be working with. This plan tells workers what you want, what service will be provided to help you, how it will be provided and how often, and any special instructions that they need to know.
  • Provider – A person or place that you have chosen to help you.
  • Provider Panel or Network – All the people or places within the five counties that can provide services. Southwest Michigan Behavioral health makes sure that these people meet certain requirements so that we know that they will do a good job and help you with your problems.
  • Occupational Therapist (OT)- A person who helps people to live more independently by helping them to master the everyday activities of life and work.
  • Severe Emotional Disturbance (SED)– Children below the age of 18 that are having trouble at school, home or in the community, and have been, or will be, for at least six months or more.
  • Seriously Mentally Ill (SMI)- Adults who have trouble with how they feel or with their thoughts or actions, which affects everything in their life.
  • Substance Abuse Disorder- People who feel that they need drugs or alcohol, or drink or take drugs in large amounts and have lost control.