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Member grievances (complaints)
A complaint is when you tell us that you aren’t happy with the quality of care or services you received from:
- One of your providers (for example, vision or dental services providers)
- A pharmacy or hospital
- Your health plan
Filing a complaint won’t affect your health care services or benefits coverage. We won’t discriminate against anyone who exercises their right to file a complaint. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue.
- You’re unhappy with the quality of care or treatment you received.
- Your provider or a plan staff member was rude to you or didn’t respect your rights.
- You had trouble getting an appointment with your provider in a reasonable amount of time.
- You received a bill from your specialist.
- You had problems reaching the transportation company for your ride.
- Your provider or a plan staff member wasn’t sensitive to your cultural needs or other special needs you have.
These are just a few examples. You may have other reasons to file a complaint.
How to file a complaint
Go to the section on this page called “File a complaint or appeal.” Choose a way to contact us. Then, follow the instructions.
Appeals
An appeal is when you disagree with a decision we made about your care. You’re asking us to review this adverse decision. And confirm our original decision was correct.
Filing an appeal won’t affect your health care services or benefits coverage. We won’t discriminate against anyone who exercises their right to file an appeal. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue.
Sometimes we make a decision about care and services that doesn’t go your way. This is an adverse decision. You’ll get a Notice of Adverse Benefit Determination (NOA). We’ll send this letter in the mail. If you don’t agree with the decision, you can ask for an appeal. The NOA letter explains how to do this. You can also send us more info you think would support a different decision.
If you don’t understand your NOA, you can:
- Call us for help at ${MS_phone_1} or ${MS_phone_2} (TTY 711), ${MS_hours}
- Email AHCCCS Medical Management
You may file an appeal because we:
- Denied the care you asked for
- Decreased the amount of care
- Ended care that was previously approved
- Denied payment for care that you may have to pay for
These are just a few examples. You may have other reasons to file an appeal.
As we explain the appeal process, we’ll include info about how long each step in the process takes:
- “Business days” means weekdays.
- “Calendar days” means all days of the week, including weekends and holidays.
How to file an appeal
Go to the section on this page called “File a complaint or appeal.” Choose a way to contact us. Then, follow the instructions.
Standard appeals
Within 60 calendar days from the date of the NOA: You must ask for your appeal in this time frame.
Within 5 business days: We’ll send you a letter saying we got your appeal.
Within 10 business days from the date on your NOA: File your appeal in this time frame if you’re asking for your services to continue while we review it.
Within 30 calendar days: We’ll resolve your appeal in this time frame, in most cases.
Extension of 14 more calendar days: This happens if we need more info to make a decision and it’s in your best interest.
Within 90 calendar days from the decision on your appeal: The time frame you have to ask for a State Fair Hearing if you disagree with an appeal denial.
Facts about time extensions
If we need an extension, we’ll tell you in writing. If we don’t get the info within 14 calendar days, we may deny the appeal.
We’ll also tell you how to file a complaint if you don’t agree with the extension.
You can also ask for an extension of 14 calendar days if you need more time to gather info for the appeal.
Next steps
Once we complete review of your appeal, we’ll send you a letter that:
- Tells you our decision
- Explains how we made it
- Explains what do if you disagree with the decision
You can speed up your appeal if you believe waiting up to 30 calendar days is harmful to your life, health or function. This is an expedited or quicker decision.
Examples of expedited appeals
You can ask for these appeals in situations that involve:
Crisis, urgent or emergency care
A new or continued hospital stay
Availability of care
Any reason with good cause
Timelines to know for expedited appeals
If your provider sends supporting info for an expedited appeal:
Within 72 hours (3 days): We’ll review your expedited appeal.
Extension of 14 more calendar days: This happens if we need more info to make a decision and it’s in your best interest.
Facts about time extensions
If we need an extension, we’ll tell you in writing. If we don’t get the info within 14 calendar days, we may deny the appeal.
We’ll also tell you how to file a complaint if you don’t agree with the extension.
You can also ask for an extension of 14 calendar days if you need more time to gather info for the appeal.
Next steps
Once we complete review of your appeal, we’ll send you a letter that:
Tells you our decision
Explains how we made it
Explains what do if you disagree with the decision
If we deny your appeal, you can ask for a State Fair Hearing. You can also ask for this hearing when:
You’ve done everything you can with our internal appeals process
The decision is still adverse (against you)
The service is clinical in nature
You have 90 calendar days from the date on the Notice of Appeal Resolution to ask a State Fair Hearing. This includes both standard and expedited requests for a State Fair Hearing.
If you decide to ask for this hearing, follow the directions in the Notice of Appeal Resolution letter. Then, Arizona Health Care Cost Containment System (AHCCCS) will send you info about what to do next. We’ll send your appeal file and related info to AHCCCS at the Office of Administrative Legal Services.
You can have a representative of your choice help you at the State Fair Hearing. Read about choosing someone to act for you later on this page.
Next steps
After the State Fair Hearing, AHCCCS will make a decision:
If they find our decision to deny your appeal was correct: You may have to pay for services you received while your appeal was in review.
If they find our decision on your appeal was incorrect: We’ll authorize and provide the services right away.
File a complaint or appeal
I want to file a complaint or appeal
You have options for filing a complaint or appeal. And we’re here to help you through the process. Tell us in detail what happened. Include any documents to support your case. Be sure to include your name and ID number. We may call you to get more info. If you don’t speak English, you can get an interpreter at no cost.
Choosing someone to act for you
You can have someone else file a complaint or appeal for you, with your written permission. This person is your member representative. They may be:
Your provider
Your family member
Your friend
Your legal guardian
Your attorney
A custodial agency representative
Another person
More about complaints and appeals
Questions? You can get more answers from your member handbook.
My language, my format
Do you need info in another language? Just call us at ${MS_phone_1} or ${MS_phone_2} (TTY 711). We’re here for you ${MS_hours}. We’ll share this info in the language you prefer. You can also get info other formats, like large print or braille.
Questions?
Call Member Services at ${MS_phone_1} or ${MS_phone_2} (TTY 711). We’re here for you ${MS_hours}.