Source: https://www.azcompletehealth.com/providers/resources/provider-manual/pm_section_8.html
Timestamp: 2019-08-17 11:09:14
Document Index: 762489932

Matched Legal Cases: ['§ 438', '§ 438', '§ 438', '§ 438', '§ 431', '§ 36', '§ 41', '§41', '§ 41', '§ 41']

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
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.
8.1 Member Grievance and Provider Complaint Process
A member may file a grievance. Any authorized representative, including a provider, may also file a grievance on behalf of a member with the member’s written consent. A grievance may be filed orally or in writing. Similarly, providers may file complaints for any reason including dissatisfaction with the Health Plan with respect to its customer service or operations.
A grievance may be initiated by contacting The Health Plan Customer Service at 888-788-4408. The Customer Service Representative (CSR) will transfer the caller to the appropriate department if the CSR is unable to resolve the caller’s concern.
A grievance may also be filed by writing to The Health Plan at the following address:
1870 W. Rio Salado Parkway Suite 2A
Fax Number: (866) 714-7998
Member or provider dissatisfaction with an authorization decision are not treated as grievances but may be appealed as described in Section 8.
Providers that are dissatisfied with respect to adjudication of a claim(s) may challenge the processing of the claim(s) as described in Section 8.
For The Health Plan members in the Serious Mental Illness (SMI) Program, additional or alternative grievance procedures may apply as outlined in Section 8.5.
For Quality of Care Concerns, The Health Plan follows the Quality of Care Concern process described in Section 10.7.
8.2 The Health Plan Grievance Resolution Process
The Health Plan follows all AHCCCS requirements with respect to the processing of member and provider grievances. Specifically, The Health Plan adheres to the following grievance resolution process:
Acknowledgement. All grievances are acknowledged within 5 business days. Grievances are acknowledged verbally or in writing based on the member’s (or other person’s) preference. Grievances received orally (in-person or by telephone) are verbally acknowledged when possible.
Communication and Information. The Health Plan assures effective communication.
The Health Plan follows requirements outlined in Section 12.14 - Cultural Competence regarding oral interpretation services, translation of written materials, and services for the deaf and hard of hearing.
All information is provided in a manner and format that may be easily understood and readily accessible to members as required by AHCCCS ACOM 405 and 42 C.F.R. § 438.10.
Resolution. The Health Plan addresses all identified issues as quickly as the circumstances dictate.
Grievances that identify an immediate clinical need or health or safety concern are addressed immediately upon receipt through an established grievance and appeal process or through another internal or external process or authority.
The Health Plan resolves most grievances within 10 days and all grievances are resolved within 90 days. Resolutions are communicated verbally or in-writing based on the preference of the grievant.
In delivering notification of resolution to the grievant, The Health Plan staff provide the member or other individual with information describing other internal or external agencies or departments that may be available to the grievant if they are dissatisfied with The Health Plan’s resolution.
Decision making. Grievance system staff consult appropriate subject-matter experts and individuals with appropriate clinical expertise when necessary to resolve a grievance and take into account all available information in reaching a resolution.
Individuals making decisions about grievances that involve the denial of an expedited resolution of an appeal or that involve clinical issues are health care professionals with the appropriate clinical expertise in treating the recipient’s condition.
Individuals who make decisions regarding grievances and appeals are individuals not involved in any previous level of review or decision making, or a subordinate of such individual(s) (See PM Sections 8.3 and 8.4).
Individuals who make decisions on grievances and appeals take into account all comments, documents, records, and other information submitted by the member or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination (See PM Sections 8.3 and 8.4).
In the event a grievant is dissatisfied with The Health Plan’s resolution of their grievance, the issue(s) in dispute may still be referred to applicable appeal and grievance processes.
The Health Plan does not route or otherwise encourage the direct filing of grievances with Arizona Health Care Cost Containment System (AHCCCS) except in limited circumstances.
8.3 Grievances and Investigations Concerning Persons with Serious Mental Illness (SMI)
The Health Plan providers are required to understand the legal rights of persons with SMI provided for in Arizona Administrative Code Title 9, Chapter 21 (9 A.A.C. 21 (PDF), Article 2. The Health Plan and its providers are required to initiate an SMI Grievance Investigation upon receipt of a non-frivolous allegation that (1) a mental health provider has violated a member’s legal rights; or (2) a condition requiring investigation exists (an incident or condition that appears to be dangerous, illegal, or inhumane, including a client death).
A request for an SMI Grievance Investigation involving an alleged rights violation or condition requiring investigation that does not involve a client death or an allegation of physical or sexual abuse shall be filed with and investigated by The Health Plan. Requests for an SMI Grievance Investigation must be submitted to The Health Plan, orally or in writing, no later than 12 months from the date the alleged violation or condition requiring investigation. This timeframe may be extended for good cause.
Any person may request an SMI Grievance Investigation by completing the Appeal or Serious Mental Illness Grievance Form (AHCCCS ACOM Chapter 400, Section 446, Attachment A) and delivering it to The Health Plan at the following address:
Fax: (866) 714-7998
A request for an SMI Grievance Investigation involving client death, physical abuse, or sexual abuse are filed with and investigated by the AHCCCS Administration pursuant to AHCCCS ACOM 446 – Grievances and Investigations Concerning Persons with Serious Mental Illness.
The Health Plan and its providers are required to report Quality of Care Concerns and Incidents, Accidents, and Deaths to The Health Plan Quality Management. (See Section 10 – Quality Management Requirements). The provider’s obligation to request an SMI Grievance Investigation as described above is separate from the provider’s reporting requirements described in Section 10 – Quality Management Requirements.
This process does not apply to allegations asserting a violation relating to the right to receive services, supports and/or treatment that are State-funded and are no longer funded by the State due to limitations on legislative appropriation;
This process does not apply to service planning disagreements more appropriately managed as appeals as described in Sections 15.3 and 15.4 and A.A.C. R9-21-405 (PDF);
This process is only available for allegations involving behavioral health services. Grievances involving physical health services or services for persons who are not in the SMI Program are managed according to Section 15.1.
Notice of Decision and Right to Appeal:
The Health Plan follows the investigation process described in Arizona Administrative Code Title 9, Chapter 21 (9 A.A.C. 21), Article 4, and in AHCCCS ACOM 446 (Grievance and Investigations Concerning Persons with Serious Mental Illness). When the investigation is concluded, The Health Plan issues a decision letter to the grievant (and the member and other authorization representatives) outlining the investigation, findings of fact, conclusions of law, and in the case of substantiated allegations, the corrective measure(s) being imposed to correct the identified deficiency or deficiencies.
If the member or authorized representative is not satisfied with the outcome of The Health Plan’s Investigation, the grievant has access to an administrative review and/or an administrative hearing as described in AHCCCS ACOM 446 (Grievance and Investigations Concerning Persons with Serious Mental Illness). To request an administrative review or administrative hearing, the appellant must send their written request to The Health Plan at the following address:
Upon receipt of a request for an administrative review or administrative hearing, The Health Plan transmits the request and the file, if any, to AHCCCS Office of Administrative Legal Services pursuant to AHCCCS ACOM 445 (Submission of Request for Hearing).
8.4 Notice Requirements and Appeal Process (Title XIX/XXI)
The Health Plan issues a Notice of Adverse Benefit Determination (NOABD) to members whenever the Health Plan makes a decision to deny or limit an authorization request or reduce, suspend, or terminate previously authorized services (collectively referred to as “adverse benefit determinations.”). The NOABD details The Health Plan’s decision and the member’s right to appeal the adverse decision in easily understood language. The Health Plan issues NOABD and processes Title XIX/XXI Appeals consistent with AHCCCS ACOM 414 (Notice of Adverse Benefit Determination and Notices of Extension for Service Authorizations)
The Health Plan members or providers may complain about the adequacy of an NOABD. If a Title XIX/XXI Member complains about the adequacy of a NOABD or its ability to be understood, The Health Plan reviews the NOABD to ensure it meets all contractual requirements as described in AHCCCS ACOM 414. If The Health Plan determines the original NOABD is inadequate or deficient, The Health Plan issues an amended NOABD. If an amended NOABD is required, the timeframe for the Member to appeal and request continuation of services (if applicable), starts to run from the date the amended NOABD was received by the member or guardian.
If a member complains to The Health Plan about the adequacy of the amended NOABD, The Health Plan is required to promptly inform AHCCCS Division of Health Care Management/Medical Management Unit (DHCM/MM) of the complaint. Additionally, The Health Plan is required to inform the member of their right to contact the AHCCCS DHCM/MM unit if the issue is not resolved to the member’s satisfaction.
8.4.1 Notice of Adverse Benefit Determination Requirements
The Health Plan issues an NOABD following:
The denial or limited authorization of a requested service;
The failure to act within the timeframes provided in 42 C.F.R. § 438.408(b)(1) and (2) for the standard resolution of grievances and appeals;
For a resident of a rural area with only one health plan, the denial of an enrollee's request to exercise their right, under § 438.52(b)(2)(ii), to obtain services outside the network; and
The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.
8.4.2 Timing of NOABD
The Health Plan issues NOABD within the following timeframe as required by AHCCCS ACOM 414:
For termination, suspension, or reduction of a previously authorized service, the notice must be mailed at least 10 days before the date of the proposed termination, suspension, or reduction except for situations providing exceptions to advance notice described in described in 42 CFR §§ 431.213-214;
For standard service authorization decisions that deny or limit services, within 14 days from the receipt of the request unless there is a Notice of Extension (refer to Notice of Extension in this manual and in 42 CFR 438.404 (c)(3));
For expedited service authorization decisions, within 72 hours from the receipt of the request unless there is a Notice of Extension;
Within 24 hours from receipt of a medication authorization request, unless additional information is needed from the prescriber in which case the determination must be made no later than seven days from receipt of the initial request; and/or
After a Notice of Extension has been issued, within 14 days of issuance of the NOE and in no event later than the 28th day after receipt of the request.
8.4.3 Title XIX/XXI Appeal and State Fair Hearing Process
A Title XIX/XXI eligible person may appeal the following adverse benefit determinations with respect to Title XIX/XXI covered services:
The denial, in whole or in part, of payment for a service that is not Title XIX/XXI covered;
The failure to provide Title XIX/XXI services in a timely manner;
The failure to act within the timeframes required for standard and expedited resolution of appeals and standard disposition of grievances; and
The denial of a Title XIX/XXI enrollee’s request to obtain services outside The Health Plan’s provider network.
A Title XIX/XXI eligible person adversely affected by PASRR determination in the context of either a preadmission screening or a resident review may file an appeal.
8.4.4 Responsibility for Processing Appeals
The Health Plan is responsible for processing all appeals; The Health Plan does not delegate this function. However, appeals that relate to PASRR determinations must be filed with and processed by AHCCCS. Information gathered during the appeal process is considered confidential and the person’s rights to privacy are protected throughout the process. The information below is provided to familiarize providers with the Title XIX/XXI appeal process.
8.4.5 Filing an Appeal
The following persons or representatives may file an appeal regarding an action:
A legal or authorized representative, (e.g., Department of Economic Security/Division of Children, Youth and Families/Department of Child Safety Specialist and/or advocate for persons with a SMI requiring special assistance), including a provider, acting on behalf of the person, with the person’s or legal representative’s written consent.
8.4.6 Timeframe for Filing an Appeal
Phone: (866) 796-0542
Email: AzCHgrievanceandappeals@azcompletehealth.com
8.4.7 Standard and Burden of Proof
The burden of proof on all issues on appeal shall be the preponderance, or the greater weight, of the evidence. The burden of proof for all issues on appeal is on the appellant (individual or agency).
8.4.8 Denial of Request for Appeal
In the event The Health Plan refuses to accept a late appeal or determines that the decision being appealed does not constitute an adverse benefit determination subject to these appeal requirements, The Health Plan will inform the appellant in writing by sending a Notice of Appeal Resolution.
8.4.9 Timeframe for resolution of a standard appeal
The Health Plan will acknowledge receipt of a standard appeal in writing within 5 working days of receipt.
The Health Plan will resolve standard appeals no later than 30 days from the date of receipt of the appeal, unless an extension is approved. A Notice of Appeal Resolution will be delivered within 30 days after the day the appeal is received.
8.4.10 Extension of standard appeal resolution timeframe
If a Title XIX/XXI eligible person requests an extension of the 30-day timeframe, The Health Plan will extend the timeframe up to an additional 14 days. If The Health Plan needs additional information and the extension is in the best interest of the member, The Health Plan may extend the 30-day timeframe up to an additional 14 days. If The Health Plan extends the timeframe it will provide a written notice to the Title XIX/XXI eligible person of the reason for the delay and issue and carry out its decision as expeditiously as the persons’ health condition requires, but no later than the date the extension expires.
8.4.11 Failure to send Notice of Appeal Resolution
If the Notice of Appeal Resolution is not sent within the timeframes set forth above, the appeal shall be considered denied on the date that the timeframe expires.
8.4.12 Circumstances for expediting an appeal
The Health Plan conducts an expedited appeal if:
The Health Plan determines or the requesting provider indicates that taking the time for a standard appeal resolution could seriously jeopardize the person’s life, physical or mental health, or ability to attain, maintain, or regain maximum function;
8.4.13 Denial of request for an expedited appeal
If The Health Plan denies a request for expedited resolution of an appeal from a Title XIX/XXI eligible person, The Health Plan will resolve the appeal within the resolution timeframes set forth above and make reasonable efforts to give the person prompt oral notice of the denial. Within two calendar days, The Health Plan will follow up with written notice of the denial.
Objections to the denial of a request for expedited resolution of an appeal shall be processed as grievances, as set forth in Section 8.0 Grievance and Appeal System.
8.4.14 Timeframe for resolution of an expedited appeal
The Health Plan will provide a written acknowledgment of the receipt of an expedited appeal within one working day after it receives the appeal.
The Health Plan will resolve expedited appeals and deliver written Notices of Appeal Resolution to the Member within 72 hours after The Health Plan receives the appeal. The Health Plan will also make reasonable efforts to provide prompt oral notice.
8.4.15 Extension of expedited appeal resolution timeframe
If a Title XIX/XXI eligible person requests an extension of the 72 hour timeframe, The Health Plan will extend the timeframe up to an additional 14 days. If The Health Plan needs additional information and the extension is in the best interest of the person, The Health Plan is required extend the three working day timeframe up to an additional 14 days. If The Health Plan extends the timeframe it will provide a written notice to the Title XIX/XXI eligible person of the reason for the delay and issue and carry out its decision as expeditious as the person’s health condition requires, but no later than the date the extension expires.
8.4.16 Notice of Appeal Resolution
A Notice of Appeal Resolution must contain:
The results of the resolution process and the date it was completed; and
For those appeals not resolved wholly in favor of the Title XIX/XXI eligible person:
The Title XIX/XXI eligible person’s right to request a State Fair Hearing by submitting a written request to The Health Plan no later than 120 days from the date of receipt of The Health Plan’s Notice of Appeal Resolution;
The right to request to receive services while the State Fair Hearing is pending, if applicable, and how to do so;
The factual and legal basis for the decision; and
An explanation that the Title XIX/XXI eligible person may be held liable for the cost of benefits being appealed if the State Fair Hearing decision results in The Health Plan decision being upheld.
8.4.17 Requesting a State Fair Hearing
A Title XIX/XXI eligible person, legal or authorized representative may request a State Fair Hearing following The Health Plan’s resolution of an appeal. The request must be in writing and submitted to:
The request must be received by The Health Plan no later than 120 days after the date that the person received the Notice of the Appeal Resolution. The Health Plan will forward the request for hearing to AHCCCS Office of Administrative Legal Services.
8.4.18 What assistance must be provided to Title XIX/XXI eligible persons in filing an appeal and/or requesting a State Fair Hearing?
Reasonable assistance must be provided to Title XIX/XXI eligible persons in completing forms and other procedural steps during the appeal process. Reasonable assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD (teletypewriter/telecommunications device for the deaf and text telephone) and interpreter capability. Reasonable assistance may be offered by a provider or referred to The Health Plan Grievance and Appeals utilizing one of the methods indicated above.
8.4.19 Continuation of Services During the Appeal or State Fair Hearing Process
The Health Plan will ensure that benefits under appeal or in the State Fair Hearing process continue unless continuation of services would jeopardize the health or safety of the person or another person if the following conditions are met:
The person files the appeal before the later of 10 days after the delivery of the Notice of Action or the effective date of the action, as indicated in the Notice of Action;
If a person wishes services to continue during appeal, they must request the continuation of services when the appeal is initially filed, and again at the time of any request for a State Fair Hearing.
8.4.20 At What Point Will a Person’s Services No Longer Be Continued during the Appeal or State Fair Hearing Process?
The Health Plan will continue services until any of the following occurs:
The AHCCCS Administration issues a State Fair Hearing decision adverse to the Title XIX/XXI eligible person.
If The Health Plan’s or the AHCCCS Director’s decision upholds a decision to deny authorization of services, and if the services were furnished solely because of the continuation requirements of Section 8.4. above. The Health Plan may recover the cost of the continued services furnished to a Title XIX/XXI eligible person.
8.4.21 Reversal of Decision to Deny Authorization of Services by the State
If The Health Plan or the State Fair Hearing decision reverses a decision to deny, limit or delay services not furnished while the appeal was pending, The Health Plan will authorize or provide the services promptly and as expeditiously as the Title XIX/XXI eligible person’s health condition requires.
If The Health Plan or AHCCCS Director's Decision reverses a decision to deny, limit, or delay authorization of services, and the Member received the disputed services while an appeal was pending, The Health Plan shall process a claim for payment from the provider in a manner consistent with The Health Plan or Director's Decision and applicable statutes, rules, policies, and contract terms (See ARS § 36-2904).
The provider shall have 90 days from the date of the reversed final agency decision to submit a clean claim to The Health Plan for payment. For all claims submitted as a result of a reversed final agency decision, The Health Plan is prohibited from denying claims as untimely if they are submitted within the 90-day timeframe.
The Health Plan is also prohibited from denying claims submitted by providers as a result of a reversed decision because the Member chooses not to request continuation of services during the appeals/hearing process: a Member’s failure to request continuation of services during the appeals/hearing process is not a valid basis to deny the claim.
8.4.22 Cooperation with AHCCCS
The Health Plan and its providers must fully cooperate with AHCCCS in the event AHCCCS decides to intervene in, participate in or review any Notice, Grievance, Appeal, SMI Grievance, or Claim Dispute or any other grievance system process or proceeding. The Health Plan will comply with or implement any AHCCCS directive within the time specified pending formal resolution of the issue.
8.5 Notice Requirements and Appeal Process (SMI and GMH/SA Non-Title XIX/XXI)
8.5.1 General Requirements for Notice and Appeals
Providers must be aware of general requirements guiding notice and appeal rights for the populations covered in this section. Providers may have direct responsibility for designated functions (i.e., sending notice) as determined by The Health Plan and/or may be asked to provide assistance to persons who are exercising their right to appeal.
8.5.1.1 Time Computed
In computing any time prescribed or allowed in this section the period begins the day after the act, event or decision occurs. If the period is 11 days or more, the time period must be calculated using calendar days, which means that weekends and legal holidays are counted. If, however, the period of time is less than 11 days, the time period is calculated using working days, in which case, weekends and legal holidays must not be included in the computation. In either case, if the final day of the period is a weekend or legal holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday.
8.5.1.2 Language, Format and Comprehensive Clinical Record Requirements
Notice and related forms must be available in each prevalent, non-English language spoken in The Health Plan’s geographic service area (GSA). As designated by The Health Plan, providers must provide free oral interpretation services to all persons who speak non-English languages for purposes of explaining the appeal process and/or information contained in the notice. The Health Plan is responsible for providing oral interpretation services at no cost to the person receiving such services.
Notice and other written documents pertaining to the appeal process must be available in alternative formats, such as Braille, large font or enhanced audio and must take into consideration any special communication needs of the person applying for or receiving services. The Health Plan is responsible for ensuring the availability of these alternative formats. The provision of notice must be documented by placing a copy of the notice in the person’s comprehensive clinical record.
8.5.1.3 Delivery of Notices and Appeal Decisions
All notices and appeal decisions must be personally delivered or mailed by certified mail to the required party, at their last known residence or place of business. In the event that it may be
unsafe to contact the person at their home, or the person has indicated that they do not want to receive mail at home, the alternate methods identified by the person for communicating notices must be used. Providers are directed to call the Provider Service Center to obtain a copy of any forms and/or attachments listed in this section, if needed, at 1-866-796-0542.
Notices pursuant to this section shall be delivered to:
The eligible person; or
The eligible person’s legal or authorized representative and for persons identified as in need of Special Assistance, this includes the person designated to meet the Special Assistance needs.
Provision of notice shall be evidenced by retaining a copy of the notice in the comprehensive clinical record of the person receiving or requesting services (See the Appeal or Serious Mental Illness Grievance Form located in the AHCCCS ACOM Chapter 400, Section 446, Attachment A)
8.5.2 Notice Requirements for Persons Being Evaluated For or with Serious Mental Illness
The following provisions apply to notice requirements for persons with SMI and for persons for which an SMI eligibility determination is being considered.
A Notice of Decision and Right to Appeal (for Individuals with a Serious Mental Illness) (Appeal or Serious Mental Illness Grievance Form located in the AHCCCS ACOM Chapter 400, Section 446, Attachment A must be provided to persons with SMI or to persons applying for SMI services when:
A decision is made to modify the service plan, or to reduce, suspend or terminate any service that is a covered service funded through Non-Title XIX/XXI funds. In this case, notice must be provided at least 30 days prior to the effective date unless the person consents to the change in writing or a qualified clinician determines that the action is necessary to avoid a serious or immediate threat to the health or safety of the person receiving services or others;
8.5.2.1 Additional Notices
The following additional notices must be provided to persons with SMI or persons applying for SMI services:
AHCCCS ACOM Policy 444, Attachment B Notice of Legal Rights for Persons with Serious Mental Illness at the time of admission to a behavioral health provider agency for evaluation or treatment. The person receiving this notice must acknowledge in writing the receipt of the notice and the behavioral health provider must retain the acknowledgement in the person’s comprehensive clinical record. All providers must post the Notice of Legal Rights for Persons with Serious Mental Illness in both English and Spanish, so that it is readily visible to behavioral health recipients and visitors;
AHCCCS ACOM Policy 444, Attachment D Notice of Discrimination Prohibited so that it is readily visible to persons visiting the agency, and a copy provided at the time of discharge from the behavioral health provider agency.
8.5.3 Notice Requirements for Non-Title XIX/XXI/Non-SMI Population
Notice is not required to persons who are not eligible for Title XIX/XXI or SMI services under this policy.
8.5.4 Appeal Requirements
Appeals must be filed with The Health Plan. The Health Plan adheres to the requirements and procedures outlined in AHCCCS ACOM Section 444 when managing appeals pursuant to this section.
Title XIX/XXI eligible persons applying for or who have been determined to have a SMI and who are appealing an action affecting Title XIX/XXI covered services may elect to use either the Title XIX/XXI appeal process (see Section 8.4 – Notice Requirements and Appeal Process for Title XIX/XXI Eligible Persons) or the appeal process for persons with SMI described in this Section 8.3, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).
8.5.4.1 Filing Persons and Entities
A State or governmental agency that provides behavioral health services through an Interagency Service Agreement/Intergovernmental Agreement (ISA/IGA) with AHCCCS, but which does not have legal custody or control of the person, to the extent specified in the ISA/IGA between the agency and the AHCCCS; and
8.5.4.2 Timeframes for Appeals
Appeals must be filed orally or in writing with The Health Plan within 60 days from the date of the decision being appealed. Late appeals must be accepted upon showing good cause.
An extension of the appeal timeframes required in this policy may be secured either at the request of the appellant or with the permission of The Health Plan Director or AHCCCS Director or designee. An extension of time may only be approved upon a showing of necessity and upon a showing that the delay will not pose a threat to the safety or security of the behavioral health recipient. Documentation of the reason for and approval of the extension of time must be maintained in the appeal case record.
8.5.5 Appeal Process for Persons with Serious Mental Illness
Decisions regarding the person’s SMI eligibility determination (this type of appeal is managed by the Crisis Response Network);
Sufficiency or appropriateness of the assessment;
Long-term view, service goals, objectives or timelines stated in the Individual Service Plan (ISP) or Inpatient Treatment and Discharge Plan (ITDP);
Recommended services identified in the assessment report, ISP or ITDP;
Actual services to be provided, as described in the ISP, plan for interim services or ITDP;
Access to or prompt provision of services;
Denial of a request for a review of, the outcome of, a modification to or failure to modify, or termination of an ISP, ITDP or portion of an ISP or ITDP;
Application of the procedures and timeframes for developing the ISP or ITDP;
Implementation of the ISP or ITDP;
Decision to provide service planning, including the provision of assessment or case management services to a person who is refusing such services, or a decision not to provide such services to the person;
Decisions regarding a person’s fee assessment or the denial of a request for a waiver of fees;
Denial of payment of a claim;
Failure of The Health Plan or AHCCCS to act within the timeframes regarding an appeal; or
A Pre-Admission Screening and Resident Review (PASRR) determination, in the context of either a preadmission screening or an annual resident review, which adversely affects the person.
8.5.6 Continuation of Services during Appeal Process
For persons with SMI, the person’s behavioral health services will continue while an appeal of a modification to or termination of a covered service is pending unless:
8.5.7 Standard Appeal Process
Within 5 working days of receipt of an appeal, The Health Plan must inform the appellant in writing that the appeal has been received and of the procedures that will be followed during the appeal.
In the event The Health Plan refuses to accept a late appeal or determines that the issue may not be appealed, The Health Plan must inform the appellant in writing that they may, within 10 days of their receipt of The Health Plan’s decision, request AHCCCS conduct an Administrative Review of the decision.
If a timely request for Administrative Review is filed with AHCCCS of The Health Plan’s decision, AHCCCS shall issue a final decision of within 15 days of the request (for persons requiring Special Assistance, see Section 12.11 - Special Assistance for Persons Determined to Have a Serious Mental Illness).
8.5.8 Informal Conference with The Health Plan
Within 7 days of receipt of an appeal, The Health Plan shall hold an informal conference with the person, guardian, any designated representative, Health Care Coordinator or other representative of the service provider, if appropriate.
The Health Plan must schedule the conference at a convenient time and place and inform all participants in writing, two days prior to the conference, of the time, date and location, the ability to participate in the conference by telephone or teleconference, and the appellant’s right to be represented by a designated representative of the appellant’s choice.
The informal conference shall be chaired by a representative of The Health Plan with authority to resolve the issues under appeal, who shall seek to mediate and resolve the issues in dispute.
The Health Plan representative shall record a statement of the nature of the appeal, the issues involved, any resolution(s) achieved, the date by which the resolution(s) will be implemented, and identify any unresolved issues for further appeal.
If the issues in dispute are resolved to the satisfaction of the person or guardian, if applicable, The Health Plan shall issue a dated written Notice of Appeal Resolution to all parties, which shall include a statement of the nature of the appeal, the issues involved, the resolution achieved and the date by which the resolution will be implemented.
If the issues in dispute are not resolved to the satisfaction of the person or guardian and the issues in dispute do not relate to the person’s eligibility for behavioral health services, the person or guardian shall be informed that the matter will be forwarded for further appeal to AHCCCS for informal conference, and of the procedure for requesting a waiver of the AHCCCS informal conference.
If the issues in dispute are not resolved to the satisfaction of the person or guardian and the issues in dispute relate to the person’s eligibility for SMI services or the person or guardian has requested a waiver of the AHCCCS informal conference in writing, The Health Plan shall:
Provide written notice to the person or guardian of the process to request an administrative hearing.
Determine at the informal conference whether the person or guardian is requesting The Health Plan to request an administrative hearing on behalf of the person or guardian and, if so, file the request with AHCCCS within 3 days of the informal conference.
For a person who is in need of special assistance, send a copy of the appeal, results of information conference and notice of administrative hearing to the Office of Human Rights (OHR).
In the event the person appealing fails to attend the informal conference and fails to notify The Health Plan of their inability to attend prior to the scheduled conference, The Health Plan shall reschedule the conference. If the person appealing fails to attend the rescheduled conference and fails to notify The Health Plan of their inability to attend prior to the rescheduled conference, The Health Plan will close the appeal docket and send written notice of the closure to the person appealing.
In the event the appellant requests the appeal be re-opened due to not receiving the informal conference notification and/or due to good cause, The Health Plan can re-open the appeal and proceed with the informal conference.
For all appeals unresolved after an informal conference with The Health Plan, The Health Plan must forward the appeal case record to the AHCCCS Office of Grievance and Appeals (OGA) within three days from the conclusion of the informal conference.
8.5.9 AHCCCS Informal Conference
Unless the person or guardian waives an informal conference AHCCCS or the issue on appeal relates to eligibility for SMI services, AHCCCS shall hold a second informal conference within 15 days of the notification from The Health Plan that the appeal was unresolved.
At least 5 days prior to the date of the second informal conference, AHCCCS shall notify the participants in writing of the date, time and location of the conference.
The informal conference shall be chaired by a representative of AHCCCS with authority to resolve the issues under appeal who shall seek to mediate and resolve the issues in dispute.
The AHCCCS representative shall record a statement of the nature of the appeal, the issues involved, any resolution(s) achieved, the date by which the resolution(s) will be implemented, and identify any unresolved issues for further appeal.
If the issues in dispute are resolved to the satisfaction of the person or guardian, AHCCCS shall issue a dated written notice to all parties, which shall include a statement of the nature of the appeal, the issues involved, the resolution achieved and the date by which the resolution will be implemented. For a person in need of Special Assistance, AHCCCS shall send a copy of the informal conference report to the OHR.
If the issues in dispute are not resolved to the satisfaction of the person or guardian, AHCCCS shall:
Determine at the informal conference whether the person or guardian is requesting AHCCCS to request an administrative hearing on behalf of the person or guardian and, if so, file the request within 3 days of the informal conference.
For a person who is in need of Special Assistance, send a copy of the notice to the Office of Human Rights.
In the event the person appealing fails to attend the informal conference and fails to notify AHCCCS of their inability to attend prior to the scheduled conference, AHCCCS may issue a written notice, within 3 working days of the scheduled conference, which contains a description of the decision on the issue under appeal and which advises the appellant of their right to request an Administrative Hearing.
In the event the appellant requests the appeal be re-opened due to not receiving the informal conference notification and/or due to good cause, the AHCCCS can re-open the appeal and proceed with the informal conference.
8.5.10 Requests for Administrative Hearing
A written request for administrative hearing shall be filed with The Health Plan for forwarding to AHCCCS. The hearing request must contain the following information:
Case name (name of the applicant or person receiving services, name of the appellant and the AHCCCS docket number);
The date of the decision being appealed; and
The Health Plan shall ensure that the written request for hearing, appeal case record and all supporting documentation is received by the AHCCCS Office of Administrative Legal Services within 3 days from such date.
Administrative hearings shall be conducted and decided pursuant to A.R.S. § 41-1092 et seq.
8.5.11 Expedited appeals
A person, or a provider on the person’s behalf, may request an expedited appeal for the denial or termination of crisis or emergency services, the denial of admission to or the termination of a continuation of inpatient services, if inpatient services are a covered benefit, or for good cause.
Within 1 day of receipt of a request for an expedited appeal, The Health Plan must inform the appellant in writing that the appeal has been received and of the time, date and location of the informal conference, or issue a written decision stating that the appeal does not meet criteria as an expedited appeal and that the appellant may request an Administrative Review from AHCCCS of this decision within 3 days of the decision. The appeal shall then proceed according to the standard process described in this section.
8.5.12 Arizona Complete Health-Complete Care Plan Expedited Informal Conference
Within 2 days of receipt of a written request for an expedited appeal, The Health Plan shall hold an informal conference to mediate and resolve the issues in dispute.
8.5.13 AHCCCS Expedited Informal Conference
Within two days of notification from The Health Plan, AHCCCS shall hold an informal conference to mediate and resolve the issue in dispute, unless the appellant waives the conference at this level, in which case the appeal shall be forwarded within one day to the AHCCCS Director to schedule an administrative hearing.
Within one day of the informal conference with AHCCCS, if the conference failed to resolve the appeal, the appeal shall be forwarded to the AHCCCS Director to schedule an administrative hearing.
8.5.14 Requests for Administrative Hearing
A written request for an administrative hearing shall be filed with The Health Plan and must contain the following information:
The Health Plan shall ensure that the written request for hearing, appeal case record and all supporting documentation is received by the AHCCCS Office of Grievance and Appeals within 3 days.
Administrative hearings shall be conducted and decided pursuant to A.R.S. §41-1092 et seq.
8.5.15 Non-SMI/Non-Title XIX/XXI Member Appeals
This process applies to actions or decisions related to determination of need for Non- SMI, Non-Title XIX/XXI funded, covered behavioral health services.
The Health Plan must:
Inform the appellant in writing within 5 working days of receipt that the appeal has been received and of the procedures that will be followed during the appeal;
Provide the appellant a reasonable opportunity to present evidence and allegations of fact or law in person and in writing; and
Provide a written decision no later than 30 days from the day the appeal is received. The decision shall include a summary of the issues involved, the outcome of the appeal, and the basis of the decision. For appeals not resolved wholly in favor of the appellant, The Health Plan will advise the appellant in writing of their right to request an administrative hearing with the AHCCCS Administration no later than 30 days from the date of The Health Plan’s decision, and how to do so.
8.6 Provider Claim Disputes
The provider claim dispute process affords providers the opportunity to challenge a decision by The Health Plan that impacts the provider for issues involving:
Payment or nonpayment of a claim;
The recoupment of payment on a claim; and
Providers may submit a claim dispute to The Health Plan, which does not delegate its claim-dispute responsibilities, when:
Challenging a decision of The Health Plan; or
Disputing a claim payment issue for services provided to persons enrolled with The Health Plan.
This section does not apply to disputes between The Health Plan and a prospective provider made in connection with The Health Plan’s contracting process.
Once The Health Plan or AHCCCS makes a decision regarding a provider claim dispute, the provider may request another review of the decision, referred to as an administrative hearing.
Many times, disagreements between a provider and The Health Plan or AHCCCS can be resolved through an informal process. Providers are encouraged to try and resolve issues at the informal level before initiating the formal provider claim dispute process. However, providers should be aware that the formal process contains very specific timeframes within which to file for a review and/or hearing and resolving issues through an informal process does not suspend or postpone these timeframes.
The intent of this section is to describe the options available to providers to resolve issues and other events related to a decision of The Health Plan or AHCCCS. The section is organized to delineate the process for filing a claim dispute:
For providers disputing a decision of The Health Plan; and
The process for requesting an administrative hearing in the event a provider does not agree with the claim dispute decision of The Health Plan or AHCCCS.
The Health Plan provides non-contracted providers with its claim dispute policy with a remittance advice within 45-days of receipt of a claim.
8.6.1 Prior To Filing An Initial Claim Dispute
All providers are encouraged to seek informal resolution of a concern by first contacting the appropriate entity responsible for the decision. For concerns regarding claims, it is important for providers to understand why the claim was denied before initiating a claim dispute. Denied claims may be the result of filing errors or missing supporting documentation, such as an explanation of benefits (EOB) or an invoice. Resubmitting claims with the requested information or corrections can result in resolution of the issue and full payment of the claim. To get assistance with the informal resolution of a decision, please contact:
Email: AzCHClaims@azcompletehealth.com
Providers are also encouraged to discuss concerns about claim processing with a Provider Engagement Specialist.
8.6.2 General Requirements
8.6.2.1 Computation of Time
A written claim dispute is considered filed when it is received by The Health Plan, as established by a date stamp or other record of receipt. Providers must use the following methodology in computing any period of time described in this chapter:
Computation of time for calendar day begins the day after the act, event or decision and includes all calendar days and the final day of the period.
If the final day of the period is a weekend or legal holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday.
If an issue is unable to be resolved informally, providers may dispute the decision by filing a written claim dispute. For all provider claim disputes related to decisions of The Health Plan, the provider must file the claim dispute with The Health Plan at:
The Health Plan utilizes a unique Docket Number for each claim dispute filed. All documentation received during the claim dispute resolution process is date stamped upon receipt.
All claim dispute case records are filed in secured locations and retained for five years after the most recent decision has been rendered.
8.6.2.2 Notification of Right to File Claim Dispute
The Health Plan provides an affected provider a remittance advice that includes providers’ right to file a claim dispute and how to do so, upon the payment, denial or recoupment of payment of a claim. The Health Plan notifies an affected provider of the right to file a claim dispute and how to do so when a decision is made to impose a sanction.
8.6.2.3 Initiating Claim Dispute
It is important for providers to ensure the claim dispute is submitted in writing and contains all required information and is filed within the required timeframes. Failure to do so will result in the denial of the claim dispute.
A notice of claim dispute must specify the statement of the factual and legal basis for the claim dispute and the relief requested. Claim disputes may be denied if the filing party has failed to provide a comprehensive factual or legal basis for the dispute.
8.6.2.4 Timeframes for Initiating Claim Dispute
For challenges relating to the payment, denial or recoupment of a claim, the later of the following:
12 months of the date of delivery of the service;
Within 60 days after the payment or denial of a timely claim submission, or the recoupment of payment, whichever is later.
8.6.3 Claim Disputes of Arizona Complete Health-Complete Care Plan re Decisions
Within 5 days of receipt of a claim dispute, The Health Plan’s issues a written acknowledgment that the claim dispute has been received, will be reviewed and that a decision will be issued within 30 days of receipt of the claim dispute, absent extension of the timeline.
If The Health Plan determines that it was not responsible for the claim dispute, it will immediately forward the claim dispute to the responsible RBHA/MCO/Health Plan or to AHCCCS with an explanation of why the claim dispute is being forwarded. A copy of the transmittal is sent by The Health Plan to the party filing the claim dispute. The receiving RBHA/MCO/Health Plan or AHCCCS must ensure that a decision is rendered within 30 days of The Health Plan’s receipt of the notice of claim dispute, unless an extension has been granted.
8.6.3.1 The Health Plan Decision
The Health Plan shall issue a written, dated decision that is mailed to all parties no later than 30 days after the provider files a claim dispute with The Health Plan, unless the provider and The Health Plan have agreed to an extension. The Decision must include and describe in detail, the following:
The Health Plan’s decision and the reasons supporting The Health Plan’s decision, including references to applicable statutes, rules, contractual provisions, and policies and procedures;
The provider’s right to request a hearing by filing a written request for hearing to AHCCCS no later than 30 days after the date the provider receives The Health Plan´s decision;
The provider’s right to request an informal settlement conference prior to hearing; and
If the claim dispute is overturned, the requirement that The Health Plan must reprocess and pay the claim(s), with interest, when applicable, in a manner consistent with the Decision within 15 business days of the date of the decision.
8.6.4 Extension of Time
The time to issue a decision may be extended upon agreement between the parties. Documentation of the agreement to the extension of time must be maintained in the claim dispute case record.
8.6.5 Requests for Administrative Hearing
If the party filing a claim dispute is dissatisfied with an AHCCCS or The Health Plan decision, or if a decision is not received within 30 days after the claim dispute is filed, absent an extension of time, a request for an administrative hearing may be filed, in writing, with The Health Plan. The Health Plan will forward the request for hearing to AHCCCS OALS.
8.6.5.1 Timeframes for Requesting an Administrative Hearing
The provider’s request for a hearing must be filed in writing and received by AHCCCS no later than 30 calendar days of the date of receipt of the AHCCCS or The Health Plan decision, absent an extension of time, or in the event no decision is rendered, within 30 days of the date of filing the claim dispute, absent an extension.
8.6.5.2 Scheduling of an Administrative Hearing
Pursuant to A.R.S. § 41-1092.03, upon receipt of a request for an administrative hearing, an administrative hearing will be scheduled pursuant to A.R.S. § 41-1092.05.
AHCCCS Office of Administrative Legal Services shall accept a written request for withdrawal from the filing party if the request is received prior to AHCCCS scheduling and mailing of a Notice of Hearing. Otherwise, a filing party who wishes to withdraw must send a written request (motion) for withdrawal to the Office of Administrative Hearings consistent with AAC R2-19-106(A)(3).
If The Health Plan’s decision regarding a claim dispute is reversed through the claim dispute or hearing process, The Health Plan will reprocess and pay the claim(s) with interest, when applicable, in a manner consistent with the decision within 15 business days of the date of the decision unless a different timeframe is specified.
8.6.6 Administrative Process
The Administrative Hearing Process is conducted according to A.R.S. Title 41, Chapter 6, Article 10.
8.6.7 Detecting Fraud And Program Abuse
The Health Plan tracks, trends and analyzes claim disputes for purposes of detecting fraud and program abuse. The Health Plan reports all suspected fraud, waste and/or program abuse involving any Title XIX funds to the AHCCCS Office of the Inspector General (OIG) consistent with the requirements in Section 9.8 – Corporate Compliance.