Complaints, grievances and appeals

Your legal rights

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.

Complaints

A complaint is when you tell us that you are not happy with any or all of your care.  A complaint can be concerns about the kind of care you are getting, concerns about how your doctor or their staff treat you, and lack of respect for your rights.

You can file a formal complaint, by calling 602-586-1719 or 1-866-386-5794 (toll free).
Or, you can file a complaint in writing by mailing it to:

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

Mercy Care RBHA has 60 days to take action, although complaints are often handled sooner.

Appeals: Title 19/21

An appeal is when you tell us that you do not agree with the decision that we made about your services. The three types of appeals are:

  1. Appeals for Title 19/21 eligible persons
  2. Appeals for persons who have a serious mental illness (SMI) determination
  3. Appeals for persons who are not SMI and non-Title 19/21 eligible

Issues that may be appealed include:

  • The denial or limited approval of a requested service, including the type or level of service
  • The reduction, suspension, or termination of a previously approved service
  • The denial, in whole or in part, of payment for a service that is not covered
  • The failure to provide covered services in a timely manner
  • The failure to act within the timeframes required for standard and expedited resolution of appeals and standard disposition of grievances
  • The denial of an enrollee’s request to obtain services outside the provider network

We will send you a written Notice of Appeal Resolution within 30 days of receiving your appeal request. We may extend the 30-day timeframe another 14 days to obtain more information. If we do, we will notify you of this delay in writing.

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

We will send you a written Notice of Appeal Resolution within 3 days of receiving your appeal request. We may extend the 3-day timeframe another 14 days to obtain more information. If we do, we will notify you of this delay in writing.

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 file an appeal in writing by mailing it to:

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

The following persons or representatives may file an appeal or request a State Fair Hearing regarding an adverse benefit determination:

  • A Title 19/21 eligible person
  • A legal or authorized representative, (e.g., Department of Economic Security/Division of Children, Youth and Families/Department of Child Safety Specialist and/or an advocate for SMI persons requiring special assistance), including a provider, acting on behalf of the person, with the person’s or legal representative’s written consent

A Title 19/21-eligible person adversely affected by a Pre-Admission Screening and Resident Review (PASRR)

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.

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.

Administrative appeals for SMI

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.

Special assistance

In some instances, persons with a serious mental illness may have other conditions that affect their ability to participate effectively in their treatment and services, such as individual service planning, inpatient treatment and discharge planning, and grievances and appeals.

Mercy Care and its providers are required to identify persons with an SMI determination who are in need of Special Assistance. A person with an SMI determination may be identified as a person in need of Special Assistance when the person is unable to communicate or participate effectively due to cognitive or intellectual impairment, or other behavioral or medical conditions.

If you meet the guidelines for Special Assistance, the AHCCCS Office of Human Rights will be notified. The Office of Human Rights may designate a person to provide Special Assistance for you and be involved throughout key stages of treatment and services.

If you have questions, you can call Mercy Care RBHA Member Services at 602-586-1841 or 1-800-564-5465; (TTY/TDD) 711. 

Or, you can call the AHCCCS Office of Human Rights at 602-364-4585 or 1-800-421-2124. Deaf or hard of hearing individuals may call the Arizona Relay Service at 711 or 1-800-367-8939 for help contacting AHCCCS.