Appeals can be filed orally or in writing within 60 days after the date of a Notice of Adverse Benefit Determination or Notice of Decision and Right to Appeal. The Notice explains to you how to file an appeal and what the deadline is for filing an appeal. However, if you have any questions the Arizona Complete Health-Complete Care Plan Grievance and Appeal Department is available to help you. To reach a Grievance and Appeal Department representative, please contact Arizona Complete Health-Complete Care Plan Member Service.
You or your legal representative can file an appeal. An authorized representative, including a provider, can also file an appeal for you with your written permission. You can also get help with filing an appeal by yourself.
In some cases, Arizona Complete Health-Complete Care Plan will review an appeal on an expedited basis. An expedited appeal is resolved within 72 hours due to the urgent health needs of the person filing the appeal. Contact Arizona Complete Health-Complete Care Plan Member Service or your provider to see if your appeal will be expedited. If your appeal is not expedited it will be resolved within 30 calendar days of the date it is received.
To file an appeal orally or for help with filing a written appeal, call 1-888-788-4408 TTY/TDD: 711. To file an appeal by mail, send your appeal and documentation to:
Arizona Complete Health-Complete Care Plan
Attn: Grievance & Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
You will get written notice that your appeal was received within 5 business days. If your appeal is expedited, you will get notice that your appeal was received within 1 business day. If Arizona Complete Health-Complete Care Plan has decided that your appeal does not need to be expedited, your appeal will follow the standard appeal timelines. Arizona Complete Health-Complete Care Plan will make reasonable efforts to give you prompt oral notice of the decision not to expedite your appeal and follow up within 2 calendar days with a written notice.
What can I appeal?
- You have the right to ask for a review of the following adverse benefit determinations:
- The denial or limited approval of a service asked for by your provider or clinical team;
- The reduction, suspension, or termination of a service that you were receiving;
- The denial, in whole or part, of payment for a service;
- The failure to provide services in a timely manner;
- The failure to act within timeframes for resolving an appeal or complaint; and
- The denial of a request for services outside of the provider network when services are not available within the provider network.
What happens after I file an appeal?
As part of the appeal process, you have the right to give evidence that supports your appeal. You can provide the evidence to Arizona Complete Health-Complete Care Plan in person or in writing. In order to prepare for your appeal, you may examine your case file, medical records, and other documents and records that may be used before and during the appeal process, as long as the documents are not protected from disclosure by law. If you would like to review these documents, contact your provider or Arizona Complete Health-Complete Care Plan. The evidence you give to Arizona Complete Health-Complete Care Plan will be used when deciding the resolution of the appeal.
How is my appeal resolved?
Arizona Complete Health-Complete Care Plan will give you a decision, called a Notice of Appeal Resolution, in person or by certified mail within 30 days of getting your appeal for standard appeals, or within 72 hours for expedited appeals. The Notice of Appeal Resolution is a written letter that tells you the results of your appeal.
The resolution date may be extended by up to 14 days. You or Arizona Complete Health-Complete Care Plan can ask for more time in order to gather more information. If Arizona Complete Health-Complete Care Plan asks for more time, you will be given written notice of the reason for the extension.
When we have completed our review, you will receive a Notice of Appeal Resolution that will tell you:
- The outcome of the appeal; and
- The reason(s) for the decision
If your appeal was denied, in whole or in part, then the Notice of Appeal Resolution will also tell you:
- How you can ask for a State Fair Hearing;
- How to ask that services continue during the State Fair Hearing process, if applicable;
- The reason why your appeal was denied and the legal basis for the decision to deny your appeal; and
- That you may have to pay for the services you get during the State Fair Hearing process if your appeal is denied at the State Fair Hearing.
What can I do if I am not happy with my appeal results?
You can ask for a State Fair Hearing if you are not happy with the results of an appeal. If your appeal was expedited, you can ask for an expedited State Fair Hearing. YOU HAVE THE RIGHT TO HAVE A REPRESENTATIVE OF YOUR CHOICE ASSIST YOU AT THE STATE FAIR HEARING.
How do I ask for a State Fair Hearing?
You must ask for a State Fair Hearing in writing within 90 days of getting the Notice of Appeal Resolution. This includes both standard and expedited requests for a State Fair Hearing. Requests for State Fair Hearings should be mailed to:
Arizona Complete Health-Complete Care Plan
Attn: Grievance and Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
Please see your member handbookfor additional details regarding the State Fair Hearing process.
