Filing Process for Members Enrolled in a Health Plan
Enrolled AHCCCS Members have the right to make a complaint, file a grievance or appeal a decision. To learn more about the process, select one of the following:
Enrolled Members must contact their health plan's Grievance and Appeals Department or call their health plan's customer service line. Detailed instructions for filing grievances and appeals may also be found in the member handbook provided by the health plan.
AHCCCS Health Plans
The health plan can answer questions about the time it will take to resolve the appeal.
A request for an expedited appeal
can be made if the member or doctor feels that the person's health will
be in serious jeopardy (serious harm to life or health or ability to attain, maintain or regain maximum function) by waiting 30 days for a decision from the health plan.
If the appeal is expedited, the health plan should resolve appeal within three working
days, absent an extension.
Members currently receiving services or benefits may be
able to continue to receive them during the appeal process. If services were reduced,
suspended or terminated, a request to continue receiving services during the appeal
may be made.
The appeal must be filed before the day the reduction, suspension or
termination is to take effect. If there is less than 10 days between the notice
date and the effective date on the notice, the request for continued services must
be filed within 10 days from the notice date. If the appeal is denied, the member
may have to pay for the services received during the appeal process.
For further information, contact the health plan or call the Office of Administrative Legal Services.
Call:
- Within Maricopa County 602-417-4232
- Statewide 1-800-654-8713 ext. 74232
If the member disagrees with the health plan's decision after the appeal, a State Fair Hearing can be requested. (A state fair hearing occurs where the appeal is presented before an administrative law judge).
The written request for a state fair hearing must be filed with the
health plan, who will forward the written request to AHCCCS to schedule a hearing. State fair hearings are only available when a health plan issues a decision on an appeal or
"action".
The health plan's decision on a grievance is final.
