My plan

Appeals and grievances

Sometimes you may get a decision or something may happen that you don't agree with. If this happens you have ways to let us know you don't agree with or like what happened. 

How to file a grievance

If you are not happy with us, your provider, or your services for any reason, you or someone who can act for you, can tell us. We want to hear from you. The problem or concern you are calling about will be handled as a grievance (another word for complaint). There are several ways you can file a grievance:

By phone: Call Member Services at 800-424-5891 (TTY 711) Monday through Friday from 8 a.m. to 6 p.m.

By email: Email MCCAZCustomerService@MagellanCompleteCare.com

By mail: Send a letter to:

Magellan Complete Care of Arizona

Attn: Grievance Coordinator

4801 E Washington St, Suite 225

Phoenix, AZ 85034

Call us if you need help with filing a grievance.

Grievance process

MCC of AZ will send you a letter to let you know we have received and are working on your grievance. We will try our best to deal with your concerns as quickly as possible to your satisfaction. We will resolve your issue within 10 business days and send you a letter with our answer. If we need to get more information, we may take up to 90 days to resolve the grievance.

If your complaint is about a Notice of Adverse Benefit Determination sent to you by MCC of AZ or you don’t understand the Notice, MCC of AZ will do a review to make sure it is clear and correct. If it is not correct we will send a corrected notice.  The timeframe for your appeal and continuation of services will start from the date of the corrected notice.

External grievance process

You can make a complaint about MCC of AZ to the AHCCCS Medical Management Helpline at 602-417-4000 (TTY 711) or 1-800-654-8713 (TTY 711) outside of Maricopa County. Or send an email to Medical Management at MedicalManagement@azahcccs.gov.

You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. You can also visit http://www.hhs.gov/ocr for more information.

Office of Civil Rights- Region III

Department of Health and Human Services

150 S Independence Mall West Suite 372

Public Ledger Building

Philadelphia, PA 19106

1-800-368-1019

Fax: 215-861-4431

TDD: 1-800-537-7697

How to file an appeal

If we do not give your doctor an okay for a service or if a service is reduced or ended, we will send you a Notice of Adverse Benefit Determination that explains why.  If you disagree with our decision, you can file an appeal asking us to take a second look. We will not treat you or your provider unfairly because you file an appeal.

Some reasons you might file an appeal are:

  • You received a denial of services – this could be either a full or partial denial
  • Care that was previously approved has been reduced or stopped
  • You received a denial of payment for a service – either whole or in part
  • You did not get services in a timely manner
  • Your grievance, appeal or request for a State Fair Hearing was not completed in the stated timeframe
  • Members in a rural areas did not get the out-of-network provider approval and there is no other provider is in the rural area.
  • Your request to dispute that you owe money for a service you received was denied

You can file an appeal within 60 days of the date on the Notice of Adverse Benefit Determination (this is the letter you will get from us in the mail). There are several ways you can file an appeal:

By phone: Call Member Services at 800-424-5891 (TTY 711) Monday through Friday from 8 a.m. to 6 p.m.

By email: Email MCCAZCustomerService@magellanhealth.com

By mail: Send a letter to:

Magellan Complete Care of Arizona

Attn: Appeals Coordinator

4801 E Washington St, Suite 225

Phoenix, AZ 85034

 

If you call us, you must also write to us within 10 days, unless you are asking for an expedited appeal. If you choose to have someone else (like a family member or your provider) file the grievance on your behalf we will need your written permission. Call us if you need help with filing an appeal.

Standard appeal process

We will send a letter to let you know we have received and are working on your appeal. Appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision and who have experience in the area of your condition or disease.

The services that you are getting may continue if you file the appeal within 10 days of the date on the Notice of Adverse Benefit Determination or by the date the change in services is scheduled to occur. If your appeal results in another denial and AHCCCS agrees with our decision, you may have to pay for the cost of any continued benefits that you received.

Before and during the appeal, you or your authorized representative can provide additional information and see your case file including medical records and any other documents being used to make a decision on your case. This information is available at no cost to you.

If we have all the information we need we will make our decision within 30 days of when we receive your appeal request.  A written letter, called a Notice of Appeal Resolution, with our decision will be sent within 3 business days from when we make the decision.

You can request an extension of up to 14 days. Or MCC of AZ may request an extension for up to 14 days if we need more information. We will call you to tell you and send written notice within 2 calendar days of the reason for the decision to extend the timeframe.  You have the right to file a grievance if you disagree with the extension.

If you do not agree with MCC of AZ’s decision on your appeal, you can request a State Fair Hearing.

Expedited appeals

If you need a decision right away, please let us know it is urgent. This occurs when your health status is in danger. If we have all the information we need we will give you an answer within 72 hours of your request. While you wait for our answer, you can continue to receive care. However, if the final decision is not in your favor, you may have to pay for the care. We will tell you our decision by phone and send a written Notice of Appeal Resolution within 1 business day from when we make the decision.

If we determine that your appeal should not be expedited, we will call you to tell you and send written notice within 2 calendar days of the reason for the decision. MCC of AZ will then resolve your appeal within the Standard Appeal timeframes.

If you do not agree with MCC of AZ’s decision on your appeal, you can request for an expedited State Fair Hearing.

State Fair Hearing request

If you do not agree with MCC of AZ’s decision of your appeal, you or your authorized representative can request a State Fair Hearing in writing within 120 days from the date on the Notice of Appeal Resolution letter from us.  Information about how to ask for a state fair hearing will be included in the Notice of Appeal Resolution letter.

To ask for a State Fair Hearing in writing, send a letter to:

Magellan Complete Care of Arizona

Attn: Appeals Coordinator

4801 E Washington St, Suite 225

Phoenix, AZ 85034