Grievance and Appeals

A grievance is a complaint you want to file because you aren't happy with health services received. Reasons to file a grievance could include: 

  • You or the member are not satisfied with the quality of care or services provided 
  • You or the member experienced rudeness of a provider or employee  
  • You or the member’s rights where not respected 

A member or a custodial agency representative can file a grievance. A provider can file a grievance on the member’s behalf, but only with the written consent of the member’s authorized representative. A grievance can be filed at any time verbally or in writing. To file a grievance, call Mercy Care DCS CHP Grievance System Department at 602-586-1719, toll-free at 1-866-386-5794, by fax at 602-351-2300 or by email at MCGandA@mercycareaz.org. 

 

You can also write to us at: 
Mercy Care DCS CHP 
Grievance System Department 
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

 

When you call to report a grievance, we will try to help resolve any concerns you have right away. If you submit your grievance in writing, we will send you a letter within five business days. The letter acknowledges our receipt of your grievance and explains how you will be notified of the resolution. 

If you submit a grievance by telephone, we may be able to resolve your concerns and tell you the resolution during the call.  

If your grievance involves concerns about the quality of care or medical treatment the member received, we will send the case to our Quality Management department.  

When we cannot resolve your grievance right away, we will let you know and explain the next steps. During our investigation of your concerns, we will work with other departments at Mercy Care as well as your health care provider(s).  

During our investigation, we may need to speak with you again. We may have more questions, or we may want to confirm that your immediate needs are met. Once the review of your grievance is complete, we will notify you of the resolution.   

If your grievance was reviewed by our Quality Management department, you will get the resolution in writing. For other cases, we will call you and explain the resolution to your grievance. If we are unable to reach you, we will send the resolution in writing. Mercy Care DCS CHP will complete a resolution and provide a response no later than 90 days after the day Mercy Care DCS CHP receives the grievance. A grievance resolution/response cannot be appealed or is not subject to a hearing. 

An appeal is a request to review an adverse decision made by Mercy Care DCS CHP.
An adverse decision is when Mercy Care DCS CHP: 

  • Denies the care requested 
  • Decreases the amount of care 
  • Ends care that has previously been approved  
  • Denies payment for care and you may have to pay for it 

 

You will know that Mercy Care DCS CHP has made an adverse decision because we will send you a letter. The letter is called a Notice of Adverse Benefit Determination (NOA). If you do not agree with the action, you may request an appeal by phone or in writing. The request must be made within 60 days from the date of the NOA. Information on how to file an appeal is provided in the NOA. 

To file an appeal you must mail, call or fax the request using the following: 

Mercy Care DCS CHP 
Grievance System Department 
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040
Phone: 602-586-1719 or toll-free 1-866-386-5794 
Fax: 602-351-2300 

Email: MCGandA@mercycareaz.org 

Request for Standard Appeal 

When we get your appeal, we will send you a letter within five business days. The letter will let you know that we got your appeal and how you can give us more information. If you are appealing services that you want to continue while the case is reviewed, you must file the appeal no later than 10 calendar days from the date on the Notice of Adverse Benefit Determination.  

In most cases, we will resolve the appeal within 30 calendar days. Sometimes, we might need more information to make a decision. When this occurs and we believe it is in the member’s best interest, we will request an extension on your appeal. An extension allows an additional 14 calendar days to complete our review and make a decision. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we still need. If we ask for an extension, you may file a grievance. The letter will explain your rights and how to submit a complaint. If we don’t receive the additional information within this time frame, we may deny the appeal. You may also request a 14-calendar day extension if you need more time to gather information for the appeal. 

Once we have completed the review of the member’s appeal, we will send you a letter with our decision. The letter tells you about our decision and explains how it was made. If we deny the member’s appeal, you may request that AHCCCS look at our decision through a State Fair Hearing. You can request this next step by following the directions we provide in the decision letter. You have 90 days from the date on the appeal denial letter to request a State Fair Hearing.  

 

Request for Expedited Appeal 

You may request an expedited resolution for the member’s appeal if you believe that the standard time frame of a standard resolution might jeopardize the member’s life, health, or ability to attain, maintain or regain maximum function. An expedited appeal is a faster review. The member’s health care provider must provide documentation to support the request for an expedited appeal.  

If we request that you send us supporting documentation from the provider but do not receive it, the appeal will be resolved within 30 calendar days. When we decide not to expedite the resolution of the appeal, we will notify you promptly. We will attempt to call you and will mail you a written notice within two calendar days that explains this outcome.  

When we expedite the resolution of the member’s appeal, we will resolve your appeal within 72 hours. Sometimes, we may need more information to make a decision. When this occurs and we believe it is in the member’s best interest, we will request extension on the appeal. An extension allows an additional 14 calendar days to complete our review and make a decision. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we need still need. If we don’t receive the additional information within this time frame, we may deny the appeal. You may also request a 14-calendar day extension if you need more time to gather information for the appeal.  

Once we have completed the review the appeal, we will send you a letter with our decision. The letter tells you our decision and explains how it was made. If we deny the appeal, you may request for AHCCCS to review our decision through a State Fair Hearing. You can request this next step by following the directions we provide in the decision letter. You have 90 days from the date on the appeal denial letter to request a State Fair Hearing.   

If you request a State Fair Hearing, you will receive information from AHCCCS about what to do. We will forward the appeal file and related documentation to AHCCCS or the Office of Administrative Legal Services.  

After the State Fair Hearing, AHCCCS will make a decision. If they find that our decision to deny the appeal was correct, you may be responsible for payment of the services you received while the appeal was being reviewed. If AHCCCS decides that our decision on the member’s appeal was incorrect, we will authorize and provide the services promptly.  

Notice of Extension 

Sometimes more information is needed to make an appeal decision. If a decision cannot be made in time, a 14 day extension may be requested. This can be done by the member, authorized custodial agency representative or Mercy Care DCS CHP. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we need still need. If we don’t receive the additional information within this time frame, we may deny the appeal. 

 

Request for a State Fair Hearing  

If the member or authorized representative disagrees with the final decision that Mercy Care DCS CHP has made on an appeal, a State Fair Hearing may be requested. The request for a State Fair Hearing must be made in writing to Mercy Care DCS CHP within 90 days from the date of the appeal decision. 

 

Mercy Care DCS CHP 
Grievance System Department 
4500 E. Cotton Center Blvd. 
Phoenix, AZ 85040 

Mercy Care DCS CHP will forward the case file and information to the AHCCCS or the Office of Administrative Legal Services (OALS). If the member or authorized representative has questions or needs more information regarding a State Fair Hearing, call the Mercy Care DCS CHP Grievance System Department at 602-586-1719 or toll-free at 1-866-386-5794. 

The member or authorized representative may request continuation of services while the appeal or state fair hearing is pending. Requests for continuation must be filed within 10 calendar days after the date Mercy Care DCS CHP mailed the NOA or the effective date of the action as indicated in the NOA. You may be required to pay the cost of services if the appeal or state fair hearing is not resolved in the member’s favor.    

Mercy Care DCS CHP and our providers cannot discriminate against anyone exercising their appeal rights or if they are filing a grievance. If you have any questions or need more information, call the Mercy Care DCS CHP Grievance System Department at 602-586-1719 or toll-free 1-866-386-5794.