Grievances & Appeals

What is an Appeal?

If you are dissatisfied with the decision made on your services, you may file an appeal within sixty (60) days following the receipt of a denial letter. The appeal can be written or verbal. If you need help with filing an appeal, call our Customer Care Center.

Who May File an Appeal?

You, as the enrollee, may file an appeal. An enrollee representative, a legal representative of a deceased enrollee's estate, or a provider acting on behalf of an enrollee, and with the enrollee's written consent, may file an appeal.

What Can You File an Appeal For?

The reasons you may file an appeal are:

• Denial or limited authorization of a requested service, including the type or level of service
• Reduction, suspension, or termination of a previously authorized service
• Denial, in whole or in part, of payment for a service
• Failure to provide services in a timely manner
• Failure to act within the timeframe required for standard and expedited resolution of appeals and standard disposition of grievances
• The denial of a rural enrollee’s request to obtain services outside the contractor’s network under 42CFR 438.52 (b)(2)(ii), when the contractor is the only contractor in the rural area

How Do You File an Appeal?

You can file an appeal by calling B – UFC/ACC's Customer Care Center. We will assist you in filing your appeal and we also provide interpretation services in any language at no cost to you.

You can file an appeal in writing and mail it to:

Banner – University Family Care/ACC
Attention: Grievances and Appeals
5255 E Williams Circle, Ste 2050
Tucson, AZ 85711

How Long Will It Take to Process an Appeal?

What is a Grievance?

A grievance is a complaint when you are not happy with the care or services you are getting, or you have concerns with how a doctor, or their staff is treating you. Examples of grievances are:

• Service issues
• Transportation issues
• Quality of care issues
• Provider office issues

How do I file a complaint? 

Call our Customer Care Center if you have a specific grievance or dissatisfaction with any aspect of your care. Our Customer Care Center will assist you in filing your complaint. B – UFC/ACC also provides interpretation services in any language at no cost to you. 

You may file your grievance in writing by mailing it to:

Banner – University Family Care/ACC
Attention: Grievances and Appeals
5255 E Williams Circle, Ste 2050
Tucson, AZ 85711

If B – UFC/ACC denies a requested service, you will receive a letter called the Notice of Adverse Benefit Determination (NOABD). You can also file a complaint regarding this letter for a denial of service by B – UFC/ACC. If we cannot take care of your concern with the adequacy of the Notice of Adverse Benefit Determination letter or have not effectively resolved the issue, you have the right to contact:

AHCCCS Office of Medical Management
Phone: (602) 417-4000
Email: MedicalManagement@azahcccs.gov
Write: Arizona Care Cost Containment System (AHCCCS)
ATTN: Division of Health Care Management
701 E. Jefferson Street, MD 8500 Phoenix, AZ 85034

How long does it take to investigate the complaint?

Our Commitment to You

Our goal is to provide high-quality medical care and advanced medical treatment. We also promise to listen, treat you with respect, and understand your individual needs. Members have rights and responsibilities. The following is a description of your rights and responsibilities.

Member Rights

You have the right to:

1. Complain to us about B – UFC/ACC and/or care provided.
2. Request information on the structure and operation of B – UFC/ACC or its subcontractors.
3. Information about B – UFC/ACC's services, health care providers, admission, transfer, discharge, billing policies, and members' rights and responsibilities.
4. Be treated fairly regardless of race, ethnicity, national origin, religion, gender, age, behavioral health condition (intellectual) or physical disability, sexual preference, genetic information, or ability to pay.
5. Be told about Physician Incentive Plans that affect referral services.
6. Know that B – UFC/ACC is required to participate in a stop-loss insurance program.
7. Be told the types of plans B – UFC/ACC uses for compensation.
8. Get a summary of member survey results.
9. Receive care that meets your needs in a way that doesn’t judge values, language, and how much a person is able to do. 
10. B – UFC/ACC and their participating providers safeguard the confidentiality of your information as required by state and federal law, including your B – UFC/ACC specific record set and your medical (care) records kept by your provider(s).
11. B – UFC/ACC specific record set: The law states that you have the right to read or get copies of your medical claim history, pharmacy claim history, grievance and appeals documents, and your B – UFC/ ACC phone call records at no cost to you from B – UFC/ACC. To receive those records, B – UFC/ACC must have the request in writing. You may make this request by calling our Customer Care Center. You will be sent an authorization form to complete and will return it to the Compliance Department with a copy of a picture ID so we can make sure we only send your records to you or someone you allow to receive your records. You can receive your records in paper form or by email (encrypted or not) if you prefer. There is some level of risk that a third party could access your Protected Health Information (PHI) without your consent when electronic media or email is unencrypted. We are not responsible for unauthorized access to unencrypted media or email or for any risks (e.g., Virus) potentially introduced to your computer/device when receiving PHI in electronic format or email.
12. Coordination of care with schools and state agencies may occur within the limits of applicable regulations.
13. A second opinion from a qualified health care professional within B – UFC/ACC's network. If an in-network second opinion is not available, you have the right to have a second opinion arranged outside of the B – UFC/ACC network at no cost to you.
14. Receive information on available treatment options and alternatives in a manner that is appropriate to your condition and is easy to understand.
15. Make Advance Directives and appoint someone to make health care decisions for you. You or your representative can change your Advance Directives at any time. You have the right to be provided with information about formulating Advance Directives. B – UFC/ACC must ensure involvement by you or your representative in decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to Advance Directives [42 C.F.R. 438.6]). For members in a HCBS or a behavioral health residential setting that have completed an Advance Directive, the document must be kept confidential but be readily available. For example: in a sealed envelope attached to the refrigerator.
16. MEDICAL CARE RECORDS: The law states that you have the right to read, or annually request and receive a copy of your medical care records at no cost to you (from any provider who provides care for you). Contact your provider to ask to see or get a copy of your medical record. You will receive a response to your request within 30 days. However, your right to access medical care records may be denied if the information is psychotherapy notes, compiled for, or in a reasonable anticipation of a civil, criminal or administrative action, protected health information subject to the Federal Clinical Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR 493.3(a)(2), or a licensed health care professional has determined that receiving or accessing your records would likely endanger the life or safety of you or another person. If your access is denied for some of these reasons, you have the right to have the denial reviewed. Providers must allow you to review your records by reading them at the provider's office or giving you a copy or both. If your provider does not give you the records or does not respond to your request within 30 days, please contact B – UFC/ACC Customer Care Center at (800) 582-8686 or TTY 711 for assistance.
17. B – UFC/ACC must reply to your request for medical records no later than thirty (30) days after receipt of your request. If B – UFC/ACC is unable to take any action within thirty (30) days, B – UFC/ACC may take an additional 30 days. B – UFC/ACC will let you know the reason for the delay and the date the request will be completed. This response will either be a copy of your records in the manner you requested, permission for you to view your records on-site, or a reason for denying your request. If a request is denied, in whole or in part, B – UFC/ACC must give you a reason for the denial and your rights to a review of the denial of access.
18. Request to have any provider who provides care for you amend or correct your medical care records that are kept by your treating provider. You may initiate this request by calling our Customer Care Center and your response will be required in writing.
19. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
20. Information needed to help you make informed decisions.
21. Receive information on beneficiary and plan information.
22. Help in decision making about your health care and Advance Directives (decisions about what kind of care you would like to receive if you become unable to make medical decisions). This includes the right to refuse treatment.
23. Be treated with respect and with due consideration for your dignity and privacy. We understand your need for privacy and confidentiality including protection of any information that identifies you.
24. Have a list of available PCPs, including those who speak a language other than English and access to a sign language interpreter for the hearing impaired.
25. Have language interpretive services from a provider who speaks your primary language, if other than English.
26. Written materials in alternate formats.
27. Seek Emergency Service at any hospital or other Emergency Room facility (in or out of network).
28. Be treated in a safe, supportive, and smoke-free environment.
29. Choose your primary care provider within the B – UFC/ACC network.
30. You or someone who represents you to take part in resolving problems about your health care decisions.
31. Involve family members or other people you choose to help you make decisions about your treatment plans.
32. Request a copy of the Notice of Privacy Practices at no cost to you. The notice describes B – UFC/ACC's privacy practices and how we use health information about you and when we may share that health information with others.
33. Request the criteria that decisions are based on.
34. Receive health care services if you are an American Indian member from any Indian Health Service provider or tribally owned and/or operated facility at any time.
35. Exercise his or her rights and that the exercise of those rights shall not adversely affect service delivery to the member [42 CFR 438.100(c)].
36. File a complaint and B – UFC/ACC will provide assistance in filing your complaint.
37. Appeal any denial of services you feel B – UFC/ACC should pay for. We will also assist you in filing an appeal.