Grievances & Appeals

Appeals

What If You Disagree with a Denied Service?

If you are dissatisfied with denial of services by B – UFC/ALTCS you may file an “appeal”. An appeal must be filed within sixty (60) days from B – UFC/ALTCS's Notice of Adverse Benefit Determination letter. The appeal can be written or verbal. If you need help with filing an appeal, call our Customer Care Center at (833) 318-4146, TTY 711.

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?

• 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 get 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?

Appeals may be requested by telephone or in writing. You may call and ask to speak to the Grievance and Appeals Team to file an appeal. You can also mail or fax the Grievance & Appeals Department. B – UFC/ALTCS will provide you with a written decision within (30) days of filing the appeal.

Additionally, the timeframes for standard and expedited appeals may be extended up to (14) days if you ask an extension or if we establish a need for an extension when the delay is in your best interest.

How Do You Request a State Fair Hearing?

If you are not satisfied with the appeal decision, you may file a request for State Fair Hearing with B – UFC/ALTCS. This request must be made in writing to B – UFC/ALTCS within 120 days of the date of receipt of the appeal decision. You can mail or fax your request. B – UFC/ALTCS will send your appeal file to AHCCCS and a hearing date will be scheduled for you to attend. AHCCCS Administration will decide if B – UFC/ALTCS's decision was correct. If AHCCCS decides that B – UFC/ALTCS's decision was incorrect, B – UFC/ALTCS will authorize and pay for services. Additionally, there are Legal Services Programs in your area that may be able to help you with the hearing process. General legal information about your rights can also be found on the internet at the following website: www.azlawhelp.org.

What Is an Expedited Appeal?

You may file an expedited appeal, or it may be filed on your behalf by your provider if you need a decision more quickly than 30 days. An expedited appeal will be approved if B – UFC/ALTCS finds that the time to process a standard appeal would seriously jeopardize your health, life or ability to attain, maintain or regain maximum function. If an expedited appeal request is not approved, B – UFC/ALTCS will notify you within 24 hours and transfer the appeal to the 30-day timeframe for a standard appeal. If we agree to accept your request for an expedited appeal, B – UFC/ALTCS will make a decision not later than 72 hours following the receipt of the authorization request with a possible extension of up to 14 calendar days if the member or provider requests an extension or if B – UFC/ALTCS establishes a need for more information and the delay is in the member's interest.

If You Are Currently Receiving the Services Requested, Can You Continue to Receive Them During the Appeal Process?

Yes, but the request must be in writing and must be received by B – UFC/ALTCS within 10 days of the receipt of the Notice of Adverse Benefit Determination letter. However, you may be responsible for payment of those services if B – UFC/ALTCS or a State Fair hearing decision upholds the denial.

Appeal Process for Members Who Have Been Determined to Have a Serious Mental Illness

Members who are found to have an SMI may appeal decisions about their behavioral health services, including:

• Decisions about fees or waivers;
• The assessment report;
• Service plans;
• Treatment plans;
• Discharge plans;
• Decisions regarding services funded through Non-Title 19/21 funds;
• Capacity to make decisions, need for guardianship, or other protective services or needs for special assistance;
• Decisions about the loss of eligibility for SMI services; and/ or
• A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the member.

In addition, members also have the right to appeal the initial determination for eligibility for SMI services. SMI eligibility appeal determinations will be handled by the Crisis Response Network, Inc.

To appeal an SMI determination, please call CRN at (855) 832-2866.

SMI Appeal Timelines

B – UFC/ALTCS will send the member a written notice within five business days of when the request for an appeal was received.

B – UFC/ALTCS will have an informal conference with the member, their legal guardian, or authorized representative within seven business days of when the appeal was received.

B – UFC/ALTCS will notify the member of the time and location of the conference, in writing, at least two days prior to the date of the conference. If the member cannot come to the conference, they can request that the conference be conducted over the phone.

If the member is satisfied with the resolution of the issue at the informal conference with B – UFC/ALTCS, they will receive a written notice that summarizes the appeal, the resolution, and the date of when the resolution will be implemented.

If a resolution is not reached at the informal grievance with B – UFC/ ALTCS, and if the appeal is not related to the member's eligibility for behavioral health services, then an informal conference will be held with AHCCCS within 15 business days of when the appeal was received. The informal conference with AHCCCS is not required and the member can request to skip the second conference.

If a resolution is still not reached at the informal conference with AHCCCS, or if the member chose to skip the informal conference with AHCCCS, then the member will be provided with information on how to request an Administrative Hearing through the AHCCCS office of Behavioral Health Grievance and Appeals.

SMI Expedited Appeal Timelines

B – UFC/ALTCS will resolve expedited appeals within 72 hours after the date of receipt of the appeal request unless an extension is in effect. B – UFC/ALTCS will extend the timeframe up to extra 14 days, if more information is needed to make a decision and the extension is in the best interest of the member.

Continuing Services During the Appeal Process

Members can continue to get services they were already receiving unless a qualified provider decides that reducing or stopping services is best for the member, or if the member agrees, in writing, to reduce or terminate services. If the appeal is not decided in the member's favor they may be required to pay for the services, they received during the appeal process.

Grievances

What If You Have Questions, Problems, or Complaints About B – UFC/ALTCS?

Call Customer Care if you have a specific grievance or dissatisfaction with any aspect of your care. Examples of grievances are: service issues, transportation issues, quality of care issues and provider office issues. Interpretation services are available in any language at no cost to you. You may call Customer Care to file a grievance (complaint). You may also file your grievance in writing by mailing it to the address listed above. Your grievance will be reviewed and a response will be provided no later than ninety (90) days from the date that you call us at (833) 318-4146.

If B – UFC/ALTCS denies a requested service, you will get a letter called the Notice of Adverse Benefit Determination (NOABD). You can also file a complaint about the adequacy of the Notice of Adverse Benefit Determination (NOABD111) letter, for a denial of service by B – UFC/ALTCS.

SMI Grievance and Request for Investigation Process

If you have been found to have a Serious Mental Illness (SMI) and feel that your rights have been violated, you have the right to file a grievance and ask for an investigation.

Members, their legal guardians, or authorized representatives can file a SMI grievance and ask for an investigation if:

• They are an adult who has been found to have a SMI.
• If the services received by the member are behavioral health services.
• The member believes their rights have been violated;
• The member believes they have been abused or mistreated by a provider or their staff; or
• The member believes that they have been subjected to illegal, dangerous, or inhumane treatment.

Members, their legal guardians, or authorized representatives have 12 months from the time their rights were violated to file an SMI grievance and ask for an investigation. SMI Grievances and requests for an investigation can be filed orally or in writing to:

Banner – University Health Plans
Attention: Grievances and Appeals
5255 E Williams Circle, Ste 2050, Tucson, AZ 85711
(833) 318-4146, TTY 711

Forms to file an SMI Grievance and request for an investigation are available at the above address or at any contracted behavioral health provider.

Once a member's SMI Grievance and request for an investigation is received, B – UFC/ALTCS will respond in writing within five days and will explain how the grievance and request for an investigation will be handled.

Grievances and requests for investigations regarding physical or sexual abuse, or death should be reported directly to AHCCCS at:

AHCCCS
Attention: Behavioral Health Grievances and Appeals
701 E. Jefferson Street, Phoenix, AZ 85034
Phone: (602) 417-4000
Fax: (602) 252-6536, TTY 711

Member Rights & Responsibilities

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:

1. You have the right to complain to us about B – UFC/ALTCS and/or care provided.
2. You have the right to ask for information on the structure and operation of B – UFC/ALTCS or its subcontractors.
3. You have the right to information about B – UFC/ALTCS's services, health care providers, admission, transfer, discharge, billing policies, and members' rights and responsibilities.  
4. You have the right to 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. You can be told about Physician Incentive Plans that affect referral services.
6. You have the right to know that B – UFC/ALTCS is required to participate in a stop-loss insurance program.
7. You can be told the types of plans B – UFC/ALTCS uses for compensation.
8. You can get a summary of member survey results.
9. You will get care that meets your needs in a way that doesn't judge race, gender, religious beliefs, values, language, how much a person is able to do, age, physical or mental disability, or ability to pay.
10. B – UFC/ALTCS and their participating providers will safeguard the confidentiality of your information as required by state and federal law. This includes your B – UFC/ALTCS specific record set and your medical (care) records kept by your provider(s). B – UFC/ALTCS 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/ ALTCS phone call records at no cost to you from B – UFC/ALTCS. To get those records, B – UFC/ALTCS must have the request in writing. You may make this request by calling our Customer Care Center or asking your B – UFC/ALTCS Case Manager. You will be sent an authorization form to complete and will return it to the Compliance Team with a copy of a picture ID so we can make sure we only send your records to you or someone you allow to get your records, or verification from the B – UFC/ALTCS Case Manager for you or your authorized representative. 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 get 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.
11. Coordination of care with schools and state agencies may occur within the limits of applicable regulations.
12. You have the right to a second opinion from a qualified health care professional within B – UFC/ALTCS'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/ALTCS network at no cost to you.
13. You can receive information on available treatment options and alternatives in a manner that is appropriate to your condition and is easy to understand.
14. You can 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/ALTCS 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.
15. MEDICAL CARE RECORDS: The law states that you have the right to read, or annually request and get 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 found 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/ALTCS Customer Care Center at (833) 318-4146 for help.
16. B – UFC/ALTCS must reply to your request for medical records no later than thirty (30) days. after receipt of your request. If B – UFC/ ALTCS is unable to take action within thirty (30) days, B –UFC/ ALTCS may take extra 30 days. B – UFC/ALTCS 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/ALTCS must give you a reason for the denial and your rights to a review o f the denial of access.
17. You have the right to ask any provider who provides care for you to 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.
18. You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
19. You have the right to the information needed to help you make informed decisions.
20. You have the right to receive information on beneficiary and plan information
21. You have the right to participate in treatment decisions. You have the right to 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.
22. You will 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.
23. You have the right to have a list of available providers, including those who speak a language other than English and access to a sign language interpreter for the hearing impaired.
24. You have the right to have language interpretive services from a provider who speaks your primary language, if other than English.
25. You have the right to written materials in alternate formats.
26. You have the right to seek Emergency Service at any hospital or other Emergency Room facility (in or out of network).
27. You will be treated in a safe, supportive and smoke-free environment.
28. You have the right to choose your PCP within the B – UFC/ALTCS network.
29. You have the right to help in decision making about your health care and Advance Directives (decisions about what kind of care you would like to get if you become unable to make medical decisions).
30. You or someone who represents you can take part in resolving problems about your health care decisions.
31. You have the right to involve family members or other people you choose to help you make decisions about your treatment plans.
32. You have the right to ask for a copy of the Notice of Privacy Practices at no cost to you. The notice describes B – UFC/ALTCS's privacy practices and how we use health information about you and when we may share that health information with others.
33. You have the right to request the criteria that decisions are based on.
34. American Indian members are able to receive health care services from any Indian Health Service provider or tribally owned and/or operated facility at any time.
35. The member has the right to 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. The member has the right for critical services. This include attendant care, personal care, homemaker and respite as authorized by the case manager. A gap in critical services happens when an agency authorized to provide the care is not able to provide the total scheduled services. When a caregiver cancels, does not show up at the scheduled time, or has to leave early, you should immediately contact the agency who scheduled the caregiver. They can offer you another caregiver to provide the care. If you do not want another caregiver in the same day, it is still important to notify the agency directly. You have a right to a replacement caregiver within 2 hours. If the gap is not resolved, you should contact your case manager for help. In the event the gap occurs after hours on holidays or weekends, call the after-hours number at (833) 318-4146. If needed, you can also file a grievance by calling our Customer Care Center. If you need further help resolving a gap in critical service, you can call AHCCCS at (800) 218-7509.