Member Grievance and Appeal ProcessAHCCCS is dedicated to serving all of our customers, including AHCCCS members, who are our primary customers, as well as providers. Members who disagree with decisions about the amount or type of services they receive can appeal these actions. They can also request a state fair hearing. Members who are unhappy about other aspects of their care can file complaints (grievances) to resolve the problem. Members must follow certain steps, beginning with contacting their health plan. Please see the Frequently Asked Questions (FAQs) below for more information about appealing an action or filing a complaint (grievance). Members Enrolled In a Health PlanIf you are enrolled in a health plan, you must appeal to your health plan. Please refer to your member handbook provided by your health plan for instructions. If you are appealing an action you must appeal to your health plan grievance department. Your health plan should resolve your appeal within 30 days unless there is an extension.
If taking the time to appeal the action would seriously jeopardize your health, you may ask for a faster review, which is called an expedited appeal. If you or your health service provider feels that your health will be in serious jeopardy if you have to wait 30 days for a decision from your health plan, you can request an expedited appeal. If your appeal is expedited, your health plan should resolve your appeal within three working days unless an extension is granted.
If you disagree with your health plan's decision after you appeal an action, you can request a state fair hearing. Your written request for a hearing must be filed with the health plan, which will forward it to AHCCCS to schedule for hearing. State fair hearings are only available when a health plan issues a decision on an action. There is no state fair hearing for a health plan's decision on a grievance (that is a complaint about something other than an "action"). The health plan's decision on a grievance is final. If you have a complaint (e.g. environmental conditions at a doctor's office, impoliteness or rudeness of providers) about something other than an action, you can file a grievance with your health plan. The health plan's decision is final; there is no state fair hearing on the health plan's decision.
Members Not Enrolled In A Health Plan (Fee-For-Service)Members not enrolled with a health plan are enrolled on a fee-for-service basis. If you are AHCCCS eligible and not enrolled with a health plan, you may contact AHCCCS Member Services with your complaint (602-417-4000 or 1-800-654-8713). If you are appealing an action you must appeal to the AHCCCS Office of Legal Assistance (OLA).
If taking the time to appeal the action would seriously jeopardize your health, you may ask for a faster review (an expedited appeal). If you or your health service provider feels that your health will be in serious jeopardy if you have to wait 30 days for a decision, you can request an expedited appeal. If your appeal is expedited, it will be scheduled directly to hearing and AHCCCS will mail a decision within three working days after the hearing.
If the AHCCCS decision on your appeal is unfavorable you may request a hearing. Your written request for a hearing must be filed with AHCCCS OLA. AHCCCS Attention: Office of Legal Assistance 701 E. Jefferson, MD 6200 Phoenix, AZ 85034 (602) 417-4232 or 1-800-654-8713 ext. 74232 Continuing Services During An AppealIf you are currently receiving services, you may be able to continue to receive them during the appeal process. If services were reduced, suspended or terminated you may ask to continue to receive services during the appeal. Services will only be continued if they have already been approved and are being provided. To continue receiving the services you must file your appeal before the day the reduction or termination is to take effect. If there is less than 10 days between the date of the notice of reduction, termination and suspension and the effective date on the notice, you have 10 days from the date of the notice to request continued services. However, if you lose your appeal, you may have to pay for the services you received during the appeal process. This is a summary of the grievance and appeal process. The complete rules can be found at Arizona Administrative Code (A.A.C.), Title 9, Chapter 34, Article 2 (enrolled members), Article 3 (non-enrolled members can be found at the Secretary of State's Office Web site).
Frequently Asked Questions (FAQs)- Who can file a complaint (grievance), appeal or request for hearing?
You may file or an authorized representative may file on your behalf. You must identify your authorized representative in writing.
- What actions can I appeal?
You can appeal any denial, reduction, suspension or termination of service, or denial of claim payment for a non-covered service. This can include a failure to act timely. These are called "actions". Examples include a denial of a request for surgery, a denial of a request for a wheelchair, a reduction in physical therapy days, etc.
- What are the time frames for filing an appeal?
Your appeal must be filed (received) no later than 60 days from the notice of action. The notice of action describes the reasons for the action, and tells you how to file an appeal.
- What if I need help filing my appeal?
Your health plan is required to provided reasonable assistance, including information on the process.
- Who will make the decision on my appeal?
A qualified health care professional will make decisions on medical decisions. The person who reviews the appeal cannot be the same person who made the original decision.
- What is a grievance?
A complaint about anything that does not involve an "action" as described in question number 2 above. The health plan's decision is final and will not be reviewed through a state fair hearing. - What do you mean when you say "seriously jeopardizing one's health?"
This means serious harm to your life or health or your ability to attain, maintain or regain maximum function.
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