Grievance And Appeals

Applicants, members, and/or their authorized representatives can file a grievance when they have a complaint about anything that does not involve appealing a decision, such as a denial or discontinuance of services or benefits.

Examples

• General Complaints
• Environmental hazard conditions at a doctor's office (dirt or clutter, unsanitary practices, overcrowded waiting areas)
• Impoliteness or rudeness of providers (doctors, doctor's office staff, hospital personnel, etc.)
• Impoliteness or rudeness of office staff (eligibility offices, AHCCCS Offices, Department of Economic Security Offices, Department of Health Services Offices, etc.)

An appeal is a request from an applicant, member, provider, health plan, or other approved entity to reconsider or change a decision, also known as an action.

An action includes any denial, reduction, suspension, or termination of a service or benefit, or a failure to act in a timely manner.

Examples

• Denial of request for surgery
• Denial of a request for a wheelchair
• Denial of basic health care services
• Denial or discontinuance of AHCCCS eligibility

Applicants have the right to make a complaint, file a grievance, or appeal a decision.

SMI Grievance/Request For Investigation

Any person may file an SMI grievance or request an investigation alleging that a rights violation or a condition requiring investigation has occurred or currently exists. (Please note: allegations about the need for, or appropriateness of behavioral health services should not be considered an SMI grievance, but should be addressed through the appeal process described below.) The request may be verbal or written and must be initiated no later than one year after the date of the alleged rights violation or condition requiring investigation. Forms for filing are available at AHCCCS, the Arizona State Hospital, the T/RBHAs, case management sites and at all provider sites.

Allegations of rights violations by a TRBHA or their providers or SMI grievances/requests for investigation related to physical or sexual abuse or death will be addressed by AHCCCS. All other SMI grievances/requests for investigation must be filed with and addressed by the appropriate RBHA. Within 7 days of the date received, you will be sent an acknowledgment letter and, if appropriate, an investigator will be assigned to research the matter. When a decision is reached, you will receive a written response.

SMI Appeal

Any person, age 18 or older, his or her guardian, or designated representative, may file an appeal related to services applied for, or services the person is receiving. Matters of appeal are generally related to: a denial of services; disagreement with the findings of an evaluation or assessment; any part of the Individual Service Plan; the Individual Treatment and Discharge Plan; recommended services or actual services provided; barriers or unreasonable delay in accessing services under Title XIX; and fee assessments. Appeals must be filed with the RBHA (or AHCCCS for the TRBHAs) and must be initiated no later than 60 days after the decision or action being appealed. Appeal forms are available at AHCCCS, the T/RBHAs, case management sites and at all provider sites.

The RBHA (or AHCCCS for TRBHA appeals) will attempt to resolve all appeals within seven days through an informal process. If the problem cannot be resolved, the matter will be forwarded for further appeal. If the RBHA will not accept your appeal or dismisses your appeal without consideration of the merits, you may request an Administrative Review by AHCCCS of that decision.

For SMI grievances/requests for investigation and appeals, to the greatest extent possible, please include:

1. Name of person filing the SMI grievance/request for investigation or appeal
2. Name of the person receiving services, if different.
3. Mailing address and phone number.
4. Date of issue being appealed or incident requiring investigation.
5. Brief description of issue or incident.
6. Resolution or solution desired.

For either process above, you may represent yourself, designate a representative, or use legal counsel. You may contact the State Protection and Advocacy System, the Arizona Center for Disability Law 1-800-922-1447 in Tucson and 1-800- 927-2260 in Phoenix. You may also contact the Office of Human Rights at (602) 364-4585, or 1-800-421-2124 for assistance. If your complaint relates to a licensed behavioral health agency, you may file a complaint online using the Licensing Services Online Complaint Form, or you can contact the Arizona Department of Health Services, Bureau of Behavioral Health Facilities Licensing by calling 602-542-1025.

Individuals who are seeking an initial SMI eligibility determination, or who are seeking to remove an existing SMI eligibility determination, have the right to file a grievance or an appeal. Solari is responsible for making SMI eligibility determinations. If you need help or have questions about SMI eligibility, you may contact Solari by calling 602-845-3594..

Process to File an Appeal

If you disagree with a determination related to your eligibility for SMI services, and you want to file an appeal, you must file your appeal with Solari within 60 days of the decision date.

• An appeal may be filed verbally or in writing.
• Online appeal form located at https://community.solari-inc.org/appeal-form/.
• A verbal appeal can be filed by calling 602-845-3594 or 1-855-832-2866.
• A written appeal can be filed by mail to:
• Attn: Solari Compliance Department
  1275 W. Washington St. Ste. 210
  Tempe, Arizona 85288

In the event an appeal is filed, a member who is designated SMI may choose to continue to receive services throughout the appeal process.

Process to File a Grievance or Make a Complaint

You may file a grievance/complaint with Solari verbally or in writing.

• Verbal grievances/complaints can be made by calling 1-844-852- 4287.
• Written grievance/complaints can be made by email at: Compliance@solari-inc.org.
• Or by standard mail to:
  
  Attn: Solari Compliance Department
  1275 W. Washington St. Ste. 210
  Tempe, Arizona 85288

For further information related to SMI determinations, please visit https://community.solari-inc.org/eligibility-and-care-services/. Refer to process and timeline at https://community.solari-inc.org/eligibility-and-care-services/timeline-steps/.

As outlined in the Intergovernmental Agreements (IGAs), TRBHAs may establish their own mechanisms for determining member SMI eligibility for utilization of block grant funding. In these instances, the TRBHA may opt out of using the statewide determination entity, Solari, for the eligibility assessment, determination, and appeal processes. Consult with the identified TRBHA program for further assistance and information:

• Gila River TRBHA: www.grhc.org/bhs, 1-888-484-8526 ext. 7100
• Navajo Nation TRBHA: www.nndbmhs.org, 1-866-841-0277
• Pascua-Yaqui TRBHA: www.pascuayaqui-nsn.gov/index.php/centered-spirit, 520-879-6060
• White Mountain Apache TRBHA: www.wmabhs.org, 928-338-4811

Enrolled AHCCCS Members have the right to make a complaint, file a grievance or appeal a decision.

Member's Process to File a Grievance or Appeal

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

Time to Resolve

The health plan can answer questions about the time it will take to resolve the appeal.

Request an Expedited 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.

Continuing Services During an Appeal

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 The General Counsel.

Call:

• Within Maricopa County 602-417-4232
• Statewide 1-800-654-8713 ext. 74232

Request a Hearing (after an unfavorable appeal)

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 health plan's decision on a grievance is final.

Members not enrolled in an AHCCCS Health Plan, including those who receive benefits through fee-for-service and/or those enrolled in the American Indian Health Plan (AIHP), have the right to file a grievance, make a complaint, or file an appeal.

Process to File a Grievance or Make a Complaint

To file a grievance or make a complaint, please call AHCCCS Office of the General Counsel:

Call:

• Within Maricopa County 602-417-4232
• Statewide 1-800-654-8713 ext. 74232

Process to File an Appeal

All appeals need to be in writing. Eligibility appeals must be sent to the agency that made the determination (AHCCCS or DES). Appeals related to denials, discontinuances, or reductions in medical services must be sent to the AHCCCS Office of the General Counsel.

To request an appeal, write the AHCCCS Office of the General Counsel:

Office Of The General Counsel
Arizona Health Care Cost Containment System Administration (AHCCCS)
150 N. 18th Ave., MD-15013
Phoenix, AZ 85007

FAX: 602-253-9115

Request an Expedited 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. If the appeal is expedited, AHCCCS should resolve the appeal within three working days, absent an extension.

Continuing Services During an Appeal

Members currently receiving services or benefits may be able to continue to receive them during the appeal process. If services or benefits 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 Office of the General Counsel.

Request a Hearing (after an unfavorable appeal)

If the AHCCCS decision on the appeal is unfavorable, a hearing referred to as a State Fair Hearing, where the appeal is presented before an administrative law judge, may be requested. A written request for a state fair hearing must be filed with the Office of the General Counsel.

Per 42 CFR § 483.15(c)(3), prior to the transfer or discharge, nursing homes must provide written notification to the resident and the resident’s representative(s). Residents can only be discharged due to one of the reasons included in 483.15(c)(1)(i).

Appeal of Transfer/Discharge Form

§ 483.15 Admission, transfer, and discharge rights.

3. Transfer and discharge -
   1. Facility requirements –
      1. The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless -
         1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
         2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
         3. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
         4. The health of individuals in the facility would otherwise be endangered;
         5. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
         6. The facility ceases to operate.
      2. The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

To obtain an appeal form, for assistance in completing an appeal, or to submit an appeal, please contact: