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. This 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 Member Services at 602-263-3000 or toll-free 1-800-624-3879 (TTY/TDD 711).
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 Department 4350 E Cotton Center Blvd. Building D 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 that we offer.

  • 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 (5) calendar 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 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.

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
Appeals Department
4755 S. 44th Place
Phoenix, AZ 85040

Phone: 602‑453‑6098 or 1‑800‑624‑3879
Fax: 602‑230‑4503

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.

Members enrolled in the Division of Developmental Disabilities (DDD) should follow the process described in this section and submit an appeal request to Mercy Care. We will conduct a review of the appeal and then forward our findings to the DDD Compliance and Review Unit. The DDD Compliance and Review Unit will examine our findings and issue a decision on the appeal. They will mail the decision letter within 30 calendar days, or within 44 calendar days when an extension was requested. The letter will explain the reason for the decision and the way you may request a fair hearing with AHCCCS if you are still not happy.

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 three (3) calendar days. 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.

DD members should file their request for expedited resolution directly with Mercy Care.

 

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.

 

If you are a person determined to have a serious or chronic mental illness, you have legal rights under federal and state law. These rights include:

  • The right to appropriate mental health services based on your individual needs
  • The right to participate in all phases of your mental health treatment, including individual service plan (ISP) meetings
  • The right to a discharge plan upon discharge from a hospital
  • The right to consent to or refuse treatment (except in an emergency or by court order);
  • The right to treatment in the least restrictive setting
  • The right to freedom from unnecessary seclusion or restraint
  • The right not to be physically, sexually or verbally abused
  • The right to privacy (mail, visits, telephone conversations)
  • The right to file an appeal or grievance when you disagree with the services you receive or your rights are violated
  • The right to choose a designated representative(s) to assist you in ISP meetings and in filing grievances
  • The right to a case manager to work with you in obtaining the services you need
  • The right to a written ISP that sets forth the services you will receive
  • The right to associate with others
  • The right to confidentiality of your psychiatric records
  • The right to obtain copies of your own psychiatric records (unless it would not be in your best interests to have them)
  • The right to appeal a court-ordered involuntary commitment and to consult with an attorney and to request judicial review of court-ordered commitment every 60 days
  • The right not to be discriminated against in employment or housing
  • The right to self-determination
  • The right to freedom of choice

If you would like information about your rights, you may request a copy of the "Your Rights in Arizona as a Person with a Serious Mental Illness (SMI)" brochure. Download a copy English | Spanish. You can also call the Arizona Health Care Cost Containment System (AHCCCS) Office of Human Rights at 1-800-421-2124 or at 602-364-4585.  

If your rights have been violated in any way, you can contact Mercy Care RBHA Member Services at 1-800-564-5465 (toll-free). People with a hearing impairment can call 711 for TTY/TDD.

Appeals: SMI

An appeal is when you tell us that you do not agree with a decision that was made about your services. Only persons with a serious mental illness (SMI) determination can use the SMI appeals process. Issues that may be appealed are, but not limited to:

  • Sufficiency or appropriateness of the assessment
  • Long-term view, service goals, objectives or timelines stated in the Individual Service Plan (ISP) or Inpatient Treatment and Discharge Plan (ITDP)
  • Recommended services identified in the assessment report, SP or ITDP
  • Actual services to be provided, as described in the ISP, plan for interim services or ITDP
  • Access to or prompt provision of services
  • Findings of the clinical team with regard to the person’s competency, capacity to make decisions, need for guardianship or other protective services or need for Special Assistance
  • Denial of a request for a review of, the outcome of, a modification to or failure to modify, or termination of an SP, ITDP or portion of an ISP or ITDP
  • Application of the procedures and timeframes for developing the ISP or ITDP
  • Implementation of the ISP or ITDP
  • Decision to provide service planning, including the provision of assessment or case management services to a person who is refusing such services, or a decision not to provide such services to the person
  • Decisions regarding a person’s fee assessment or the denial of a request for a waiver of fees
  • Denial of payment of a claim
  • Failure of the RBHA or AHCCCS to act within the timeframes regarding an appeal; or

A PASRR determination, in the context of either a preadmission screening or an annual resident review, which adversely affects the person.

We will notify you in writing within five days that we have received your request for an appeal. Within seven days of receiving your appeal we will schedule a meeting with you and your authorized representative to discuss the appeal.

An expedited appeal is an appeal that needs to be reviewed urgently. You can appeal any denial of crisis or emergency services, inpatient services, or denial for good cause.

We will notify you in writing within one day that we have received your request for an expedited appeal. Within two days of receiving your appeal we will schedule a meeting with you and your authorized representative to discuss the appeal.

An appeal must be filed within 60 days of when you are informed of the adverse benefit determination being appealed. If you go over that timeframe, we can still review your request for good cause.

You can file an appeal by calling 602-586-1719 or 1-866-386-5794 (toll free). You can also appeal in writing by mailing your appeal to:

Mercy Care RBHA
Attn: Grievance and Appeals Department
4755 S. 44th Place
Phoenix, AZ 85040

You can always file for yourself. If you aren't able to do so, any person from the list below can file for you:

  • An adult’s legal guardian, guardian ad litem, designated representative or attorney
  • A legal guardian or parent who is the legal custodian of a person under the age of 18 years
  • A court appointed guardian ad litem or an attorney of a person under the age of 18 years
  • A state or governmental agency that provides behavioral health services through an ISA/IGA with AHCCCS, but which does not have legal custody or control of the person, to the extent specified in the ISA/IGA between the agency and the AHCCCS
  • A provider, acting on the behavioral health recipient’s behalf, and with the written authorization of the person

In most cases, yes. Your services will continue unless we find that to change or continue your services could be a serious threat to your health or safety or the health or safety of others.

SMI grievance or request for investigation

A grievance or request for investigation is when you tell us that your rights, as person with a serious mental illness (SMI) determination, have not been respected. You can request this when any issue needs to be further investigated.

You have one year from the event to file a grievance or request for investigation.

We will notify you in writing within 5 days that we have received your grievance or request for investigation. We will resolve this request as quickly as possible. We will send you a written notice of the final outcome once the investigation is completed.

We may extend the timeframe to obtain more information. If we do, we will notify you of this delay in writing.

You can file a grievance or request for investigation by calling 602-586-1719 or 1-866-386-5794 (toll free). You can also file a grievance or request for investigation in writing by mailing it to:

Mercy Care
Attn: Grievance and Appeals Department
4755 S. 44th Place
Phoenix, AZ 85040

You can always file for yourself. If you are not able to do so, anyone can file a grievance or request for investigation on your behalf.

You may file a request for an administrative appeal.

An administrative appeal is when you tell AHCCCS that you do not agree with the outcome of your grievance investigation.

You must file your request for an administrative appeal within 30 days of receiving the written outcome of the investigation.

In a written statement include all your reasons why you do not agree with the outcome. Send your written request to:

AHCCCS Office of Grievance and Appeals
801 E. Jefferson, MD 6200
Phoenix, AZ 85034
602-364-4575

Or, you can call the AHCCCS Clinical Resolution Unit at 602-364-4558. Deaf or hard of hearing individuals may call the Arizona Relay Service at 711 or 1-800-367-8939 for help contacting AHCCCS.

You can file an administrative appeal for yourself. For help filing the appeal, you can contact Mercy Care RBHA Member Services 1-800-564-5465 (toll-free) or hearing impaired (TTY/TDD 711).

You can ask for a State Fair Hearing if you are not happy with the results of an appeal. If your appeal was expedited, you can ask for an expedited State Fair Hearing. You have the right to have a representative of your choice assist you at the State Fair Hearing.

You must ask for a State Fair Hearing in writing within 30 days of getting the Notice of Appeal Resolution. This includes both standard and expedited requests for a State Fair Hearing.

Requests for State Fair Hearings for decisions issued by Mercy Care RBHA should be mailed to:

Mercy Care
Attn: Grievance and Appeals Department
4755 S. 44th Place
Phoenix, AZ 85040

Instructions for appealing a decision issued by AHCCCS will be contained in the Notice of Appeal Resolution.