Grievance and Appeal System

The Health Plan members and providers have access to a grievance system that fairly and efficiently reviews, and resolves identified issues. The Health Plan grievance system staff address member, provider, and stakeholder concerns in a courteous, responsive, effective, and timely manner. This section provides an overview of the following grievance system processes:

  • Member Grievances and Provider Complaints;
  • Grievances and Investigations Concerning Persons with Serious Mental Illness (SMI);
  • Notice Requirements and Appeal Process (TXIX/XXI);
  • Notice Requirements and Appeal Process (Non-Title XIX/XXI (SMI and GMH/SA)); and
  • Provider Claim Disputes

Providers must understand The Health Plan grievance system in order to assist members who wish to utilize a grievance system process. Grievance system processes also afford providers a formal process for expressing dissatisfaction, including but not limited to dissatisfaction regarding nonpayment of a claim, imposition of sanctions, and service denials.

Providers are required to fully cooperate with grievance and appeal system staff with respect to grievance system processes.  This includes, but is not limited to:

  • Ensuring members are provided all Enrollee rights as provided for in 42 C.F.R. § 438.100.  See also Provider Manual Section 9.1, Member Rights.
  • Providing education to members about their rights and making that information readily available to members upon request.  This includes, but is not limited to, providing and posting AHCCCS ACOM Policy 444, Attachment D Notice of Discrimination Prohibited and AHCCCS ACOM Policy 444-Attachment B-Notice of Legal Rights for Persons with Serious Mental Illness);
  • Assisting members who wish to utilize a grievance system process.  This includes, but is not limited to, assisting a member with reducing a grievance or appeal to writing and/or assisting a member with calling Customer Service;
  • Responding to inquiries from staff within the specified timeframe and if no timeframe is specified, within a reasonable amount of time;
  • Producing clinical records to grievance system staff upon request when review of such records, in The Health Plan’s discretion, is necessary to resolve a member or provider concern;
  • Making staff available to respond to inquires upon request;
  • Adhering to all corrective actions or directives imposed by the Health Plan within the specified timeframes; and
  • Adopting policies and procedures to ensure compliance with health plan and AHCCCS policy, including policies that prohibit retaliation against members or other persons who file grievances.

Providers who fail to cooperate with grievance system staff may be subject to corrective actions, sanctions, or other remedies as described in this manual and in the Participating Provider Agreement.

The Health Plan does not retaliate against any member or provider who exercises their rights. The Health Plan does not take punitive action against a provider who supports a member’s appeal or who supports an expedited resolution of an appeal.  Similarly, health plan providers shall not take punitive action against any person who exercises their rights in any manner, including through an established grievance system process.