Grievance and Appeals

A grievance is any expression of dissatisfaction related to the delivery of your health care that is not defined as an appeal. A grievance is also called a complaint. You may have a problem with a doctor or felt that office staff treated you poorly. You may have received a bill from your specialist or had difficulty reaching the transportation company for your ride home. A grievance might include concerns with the quality of the medical care you received. Please let us know if you have a concern like this or need help with another problem. The fastest way to report a grievance is to call Mercy Care Grievance System Department Monday through Friday 7 a.m. to 6 p.m. at 602‑586-1719 or 1‑866‑386‑5794 (TTY/TDD 711). You may also contact Member Services if you need help filing your grievance, have a hearing impairment, need an interpreter or would like the information provided in an alternate format or language. A representative will document your grievance. It is important to provide as much detail as possible. The representative will explain the grievance resolution process and answer any other questions you may have. We may also need to call you back to provide updates or ask you for more information. We want to ensure that you are receiving the care and services you need.

If you prefer to file your grievance in writing, please send your complaint to:

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

Filing a grievance will not affect your future health care or the availability of services. We want to know about your concerns so we can improve the services we offer.

• When you submit your grievance in writing, we will send you a letter within five (5) business days. The letter acknowledges our receipt of your grievance and explains how you will be notified of the resolution.

• If your grievance involves concerns about the quality of care or medical treatment you 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.

• We are committed to resolving your concerns as quickly as possible and in no more than 90 days from the date you submitted your grievance.

 

Arizona Health Care Cost Containment System (AHCCCS) is committed to ensuring the availability of timely, quality behavioral health care. If you continue to have questions or difficulties accessing services, please call AHCCCS Clinical Resolution Team at 602‑364‑4558 or 1‑800‑867‑5808 or you may submit concerns about quality of care by email at CQM@azahcccs.gov.

 

If you disagree with our decision described in the Notice of Adverse Benefit Determination letter, you have the right to request an appeal. An appeal is a formal procedure asking us to review the request again and confirm if our original decision was correct. During this process, you may submit additional supporting documents or information that you believe would support a different outcome and decision.

You, your representative, or a provider acting with your written permission, may request an appeal with us. If you need help filing your appeal, have a hearing impairment, need an interpreter or would like the information provided in an alternate format or language, please call Mercy Care Member Services Monday through Friday, 7 a.m. to 6 p.m. at 602‑263‑3000 or 1‑800‑624‑3879 (TTY/ TDD 711). If you decide to file an appeal, it must be submitted within 60 calendar days from the date on your Notice of Adverse Benefit Determination letter. The appeal may be submitted in writing or by telephone. We will not retaliate against you or your provider for filing an appeal.

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

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

602-586-1719 or 1-866-386-5794
Fax: 602-351-2300

Request for Standard Appeal

When we get your appeal, we will send you a letter within five (5) calendar days. This 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 your case is reviewed, you must file your appeal no later than 10 calendar days from the date on the Notice of Adverse Benefit Determination letter.

In most cases, we will resolve your appeal within 30 calendar days. Sometimes, we might need more information to make a decision. When this occurs and we believe it is in your 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 timeframe, 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 your 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 your 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 120 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 your appeal file and related documentation to AHCCCS at the Office of Administrative Legal Services. After the State Fair Hearing, AHCCCS will make a decision. If they find that our decision to deny your appeal was correct, you may be responsible for payment of the services you received while your appeal was being reviewed.

If AHCCCS decides that our decision on your appeal was incorrect, we will authorize and provide the services promptly.

Request for expedited resolution

You or your representative can request an expedited resolution to your appeal if you believe that the timeframe of a standard resolution might jeopardize your life, health or ability to attain, maintain or regain maximum function. We may ask you to send us supporting documentation from your provider. If your provider agrees, we will expedite the resolution of your appeal. We will also automatically expedite the resolution of your appeal if we believe following the standard resolution process could jeopardize your life or health.

If we request that you send us supporting documentation from your provider but do not receive it, your appeal will be resolved within 30 calendar days. When we decide not to expedite the resolution of your appeal, we will notify you promptly. We will attempt to call you and will mail you a written notice within two (2) calendar days that explains this outcome. For more information, please see “Request for Standard Appeal” in this handbook. If we change the urgency of your appeal from expedited to standard, you may file a grievance. We will explain this when we call you. We will include information about how to file a grievance in the letter we mail to you. When we expedite the resolution of your 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 your best interest, we will request 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 need still need. If we don’t receive the additional information within this timeframe, 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 your 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 your 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 120 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 your appeal file and related documentation to AHCCCS at the Office of Administrative Legal Services.

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

Quick tips about denial, reduction, suspension or termination of services and appeals

• You will get a letter (Notice of Adverse Benefit Determination) when a service has been denied or changed.

• If you want to ask for a review (appeal) of Mercy Care’s action, follow the directions in your notification letter.

• To request that services be continued, you must file your appeal no later than 10 days from the date of your notification letter, or within the time frame listed in the notification letter.

If the Notice of Adverse Benefit Determination letter does not fully address your concerns, you can contact AHCCCS Medical Management at MedicalManagement@azahcccs.gov.