Members

Grievances and Appeals

Grievances

If you have a concern with any part of your health care, or you would like to complain about Health Choice Arizona, please contact Member Services. The problem or concern you are calling will be handled as a grievance (another word for complaint).

FILING A GRIEVANCE

If you are not happy with any health care you received, you have the right to file a grievance. You can also file a grievance about Health Choice Arizona. This gives you a chance to tell us about your concerns.

You can file a grievance about issues related to your health care such as:

  • Timeliness
  • Whether care of treatment is appropriate
  • Access to care
  • Quality of care
  • Staff attitude
  • Rudeness
  • Any other kind of problem you may have had with your health care service

You can file a grievance either over the phone or in writing.

To file a grievance by phone:

  • Call Member Services and we will help you.
  • The representative will ask you about the concern. This will help us get all of the information necessary to address your matter.
  • Tell the representative the date the problem happened and any other facts about the issue.

To file a grievance in writing, send a letter to:

Health Choice Arizona
Attn: Member Grievances
410 N. 44th St., Suite 500
Phoenix, AZ 85008

Health Choice Arizona will carefully look into your concern. We are here to help you. We may contact you for more information or talk to others involved in your care. Once the review is complete, we will send you a letter telling you the outcome.

Please note: You also have the right to contact the AHCCCS Medical Management Department if you do not feel that Health Choice Arizona has not resolved your concerns about the adequacy of a Notice of Action letter. The AHCCCS Medical Management Department can be reached by phone at 602-417-4000 or in writing at AHCCCS Attn: Medical Management Department, 701 E. Jefferson Street, Phoenix, AZ 85032.

 

Appeals

Health Choice Arizona may deny services that your doctor asks for, or we may limit or stop your care. If this happens, you will get a letter from Health Choice. This is called a Notice of Action (NOA) letter.

The NOA will explain the decision and why we made it. It will tell you the law, rule or policy that was used to make the decision. It will give you the date the decision was made.

The NOA will explain how to ask for a second review if you do not agree with our decision. The NOA will tell you how to continue services during the appeal process. This review is called an appeal. We will tell you how to continue getting services during the appeal process.

The NOA will also explain that if you lose the appeal, you will have to pay for care you got during the appeals process. Before you file an appeal, check with your doctor. Your doctor could have a different plan of care that may be covered. The care plan may include other treatment you can get that will have the same result for you.

REQUESTING AN APPEAL

If you disagree with the Notice of Action (NOA), you can request an appeal. You can ask for an appeal by calling Member Services, or by writing a letter to Health Choice Arizona.

To file an appeal by phone:

  • Call Member Services at 800-322-8670 (TTY 711) and a representative will help you.
  • Have your Notice of Action with you when you call. This will help us get all of the information necessary to address your matter.

To file an appeal in writing:

  • Your appeal letter must be sent directly to Health Choice Arizona.
  • Do not send your appeal to AHCCCS.
  • Mail your letter to: Health Choice Arizona Attn: Member Appeals 410 N. 44th St., Suite 900 Phoenix, AZ 85008.

You have 60 calendar days from the date of Health Choice Arizona’s Notice of Action or the date of any adverse action to file your Appeal. Health Choice will send you a letter stating we received your request. This will be sent to you within five working days.

You may ask to look at the information we are reviewing to make our decision. You may ask to see records at any time during the Appeal process. You can also send us more information if you think it will help us with our review. This includes having us talk to people involved in your care, such as another provider or family member.

Health Choice Arizona will have someone review your file who had nothing to do with your first Notice of Action that denied, limited or stopped care we said you could have. We will make a decision about your appeal within 30 days.

After Health Choice Arizona has looked at your appeal, we will send you a letter to tell you our decision. This letter is called a Letter of Appeal Resolution.

EXPEDITED APPEAL

If you cannot wait 30 days for a decision, you can ask Health Choice Arizona to make a decision faster. You can ask for a faster decision if waiting 30 days could cause serious harm to your health, life or your ability to reach, get back to or keep functioning at a maximum level. This is called an Expedited Appeal.

The Expedited Appeal process follows the same steps as a standard appeal, except the decision is made in 72 hours, rather than 30 days.

We will call to tell you our Appeal decision. You will also receive a Notice of Expedited Appeal Resolution letter. This letter will tell you our decision. If Health Choice Arizona does not agree that a fast decision has to be made, then a decision will be made within 30 days.

You will receive a Notice of Appeal Resolution Letter, which will tell you our decision.

NOTICE OF EXTENSION

Health Choice Arizona will answer your appeal request as quickly as we can. However, sometimes it is in your best interest for us to take more time to make a decision. We will send you a letter if we need more time. That letter is called a Notice of Extension. This means Health Choice Arizona has 14 more days to make a decision.

We will also let you know how you can file a complaint if you do not agree that Health Choice should take more time. If you need more time, you can request an extension. This may help you get all the information you need for your appeal.

USING A REPRESENTATIVE

If you choose to appeal the Notice of Action (NOA), you have the right to get help. You can file the appeal yourself or you can have someone file it for you. The person helping you is called your “representative.”

A representative may be a family member, a provider, or an attorney if you wish. The process is the same whether you file the appeal yourself or have someone help you. The time frame is also the same in either case.

When Health Choice sends you the NOA, we also send a list of agencies that may help you file your appeal. If you need another list, please call Member Services. You can also get help filing your appeal from a family member, friend, clergy or even your doctor.

Send us a letter telling us the name of your representative. Tell us in the letter that you want to allow your representative to file the appeal for you. If you do not have someone to help you, and you would like our help finding you someone, please write us a letter. To tell us about your representative, please mail your letter to: Health Choice Arizona Attn: Member Appeal 410 N. 44th St., Suite 900 Phoenix, AZ 85008.