Grievance and Appeals

Grievance

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. You also have the right to file a complaint if you do not feel a Notice of Adverse Benefit Determination letter was adequate. 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 Member Services Monday through Friday 7 a.m. to 6 p.m. at 602-263-3000 or 1-800-624-3879 (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 Department
4755 S. 44th Place
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 call to report a grievance, we will try to help resolve the concern(s) 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 over the telephone, we may be able to resolve your concern(s) 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.

Grievance/Request for Investigation for members determined to have a serious mental illness (SMI)

A member enrolled in the Arizona Long Term Care System (ALTCS) who is determined to have a serious mental illness (SMI) is entitled to extensive rights, including, but not limited to:

The right to be free from mistreatment and abuse.
The right to a written service plan that may include case management, crisis services, peer support, family support, medication and inpatient/outpatient services.
The right to consent or refuse treatment unless under a court order or guardianship.
The right to review the medical records unless a physician determines it is not in the member’s best interest.

An SMI grievance is a request to investigate whether a member had his or her right’s violated. This request can be filed by anyone but must be submitted within 12 months from the date of the incident. It is important to provide all details such as events, names of individuals involved, titles, agencies and dates. It is also important to focus on the facts and include the resolution you want. You may request an SMI grievance orally by contacting Mercy Care. If you would like to submit an SMI grievance in writing, please mail your request to Mercy Care at the address shown in this section.

If you need help writing your grievance, contact your behavioral health provider or the AHCCCS Office of Human Rights (OHR), at 602-364-4585 (Phoenix), 520-770-3100 (Tucson) or 928-214-8231 (Flagstaff). If you need documents, such as medical records or individual service plans, to support your grievance, you have the right to request these records.

Grievances concerning physical abuse, sexual abuse or a person’s death are investigated by AHCCCS. To file a grievance concerning physical abuse, sexual abuse or a person’s death, contact:

AHCCCS Office of Grievance and Appeals
801 E. Jefferson MD 6200
Phoenix, AZ 85034
Phone: 602-364-4575
Fax: 602-364-4591

Deaf or hard of hearing individuals may call the Arizona Relay Service at 711 or 1-800-367-8939 for help contacting AHCCCS.

If you file an SMI grievance/request for Investigation, the quality of your care will not suffer.

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.

Appeals

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.

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.

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.

Appeals for members determined to have a serious mental illness (SMI)

A serious mental illness (SMI) is a mental disorder in persons 18 years of age or older that is severe and persistent. Crisis Response Network, a provider that has a contract with Mercy Care, will make a determination of serious mental illness upon referral or request. Members asking for a determination of serious mental illness and members who have been determined to have a serious mental illness can appeal the result of a serious mental illness determination.

Crisis Response Network will send you a letter by mail to let you know the final decision on your SMI determination. This letter is called a Notice of Decision. The letter will include information about your rights and how to appeal the decision. If you do not agree with the results of the SMI eligibility determination you may file an appeal. To file an appeal, you can call Crisis Response Network at 1-855-832-2866.

Members determined to have a serious mental illness may also appeal the following adverse decisions:

Initial eligibility for SMI services
A decision regarding fees or waivers
The assessment report, and recommended services in the service plan or individual treatment or discharge plan
The denial, reduction, suspension or termination of any service that is a covered service funded through Non-Title 19/21 funds
Capacity to make decisions, need for guardianship or other protective services, or need for special assistance
A decision is made that the member is no longer eligible for SMI services
A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the member

To file an appeal, you must call or send a letter to:

Mercy Care Appeals Department
4755 S. 44th Place
Phoenix, AZ 85040
602-453-6098 or 1-800-624-3879
Fax: 602-230-4503

If you file an appeal you will continue to get any services you were already getting unless:

A qualified clinician decides that reducing or terminating services is best for you,
Or, you agree in writing to reducing or terminating services.

If the appeal is not decided in your favor, Mercy Care may require you to pay for the services you received during the appeal process.

If you or your representative still do not understand the Notice of Adverse Benefit Determination letter, you have the right to contact AHCCCS Medical Management at MedicalManagement@azahcccs.gov.