Grievances & Appeals


Appeals

Appeal and Request for Fair Hearing

What if You Disagree with a Denied Service?

If you are dissatisfied with denial of services by BUFC/ACC you may file an “appeal”. An appeal must be filed within sixty (60) days from BUFC/ACC's Notice of Adverse Benefit Determination letter. The appeal can be written or verbal. If you need assistance with filing an appeal, call Customer Care at (800) 582-8686.

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?

Appeals may be requested by telephone or in writing. You may call our Customer Care Center and ask to speak to an Appeals Representative to file an appeal. You can also mail or fax the Grievance & Appeals Department. BUFC/ACC will provide you with a written decision within thirty (30) days of filing the appeal.

Additionally, the timeframes for standard and expedited appeals may be extended up to fourteen (14) days if you request an extension. We may 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 BUFC/ACC. This request must be made in writing to BUFC/ACC within 120 days of the date of receipt of the appeal decision.

You can mail or fax your request. BUFC/ACC will send your appeal file to AHCCCS and a hearing date will be scheduled for you to attend. AHCCCS Administration will decide if BUFC/ACC's decision was correct. If AHCCCS decides that BUFC/ACC's decision was incorrect, BUFC/ACC 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 thirty (30) days. An expedited appeal will be approved if BUFC/ACC determines 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, BUFC/ ACC will notify you within 24 hours. Then it will be transfered to the 30-day timeframe for a standard appeal. If we agree to accept your request for an expedited appeal, BUFC/ACC will make a decision not later than 72 hours following the receipt of the authorization request. There is a possible extension of up to fourteen (14) calendar days if the member or provider requests an extension or if BUFC/ACC establishes a need for additional 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 BUFC/ACC 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 BUFC/ACC or a State Fair Hearing decision upholds the denial.

Contact information for Grievance & Appeals:

Banner – University Health Plans
Attn: Grievance & Appeals Department
2701 E. Elvira Road, Tucson, AZ 85756
Phone: (800) 582-8686, ask for Grievance & Appeals
Fax: (520) 874-3462 or (866) 465-8340


Grievances

What If You Have Questions, Problems, or Complaints about BUFC/ACC?

Call our Customer Care Center 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. You may call our Customer Care Center to file a grievance (complaint) or you may file your grievance in writing by mailing it to the address listed above.

If BUFC/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 the adequacy of the Notice of Adverse Benefit Determination (NOABD111) letter, for a denial of service by BUFC/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

When you receive your NOABD in the mail, you will see a section in that letter called `Facts about Your Condition or Situation That Support our Decision'. If you do not understand the facts of the decision in this section, call our Customer Care Center at the available phone number included in the NOABD to get more specific information. BUFC/ ACC uses the most current evidence based medical guidelines in this country, for all clinical decision making. You and your provider can request those guidelines or any other information that was used to make the decision. We want you and your provider to be able to fully understand the reason and evidence-based criteria that were used.


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 BUFC/ACC and/or care provided.
  2. You have the right to request information on the structure and operation of BUFC/ACC or its subcontractors.
  3. You have the right to information about BUFC/ACC'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 BUFC/ACC is required to participate in a stop-loss insurance program.
  7. You can be told the types of plans BUFC/ACC uses for compensation.
  8. You can get a summary of member survey results.
  9. You will receive 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. BUFC/ACC and their participating providers will safeguard the confidentiality of your information as required by state and federal law, including your BUFC/ACC specific record set and your medical (care) records kept by your provider(s).
  11.  BUFC/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 BUFC/ ACC phone call records at no cost to you from BUFC/ACC. To receive those records, BUFC/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. You have the right to a second opinion from a qualified health care professional within BUFC/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 BUFC/ACC network at no cost to you.
  14. You can receive information on available treatment options and alternatives in a manner that is appropriate to your condition and is easy to understand.
  15. 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 (BUFC/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 BUFC/ACC Customer Care Center at (800) 582- 8686 for assistance.
  17. BUFC/ACC must reply to your request for medical records no later than thirty (30) days. after receipt of your request. If BUFC/ACC is unable to take action within thirty (30) days, BUFC/ACC may take an additional 30 days. BUFC/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, BUFC/ACC must give you a reason for the denial and your rights to a review of the denial of access.
  18. You have the right to 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. You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  20. You have the right to the information needed to help you make informed decisions.
  21. You have the right to receive information on beneficiary and plan information.
  22. 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.
  23. 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.
  24. You have the right to 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. 20.
  25. You have the right to have language interpretive services from a provider who speaks your primary language, if other than English.
  26. You have the right to written materials in alternate formats.
  27. You have the right to seek Emergency Service at any hospital or other Emergency Room facility (in or out of network).
  28. You will be treated in a safe, supportive and smoke-free environment.
  29. You have the right to choose your primary care provider within the BUFC/ACC network.
  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 request a copy of the Notice of Privacy Practices at no cost to you. The notice describes BUFC/ACC'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)].