Grievance and Appeals
Provider Complaint/Grievance and Appeal Process
Claim Complaints must follow the Dispute process and then the Complaint Process below. Medical necessity and authorization denial complaints are handled in the Appeal process below. Please note that claim payments are not appealable. These must be handled via the Claim Dispute and Complaint process. Claim Disputes may be mailed to:
Ambetter from Arizona Complete Health
Attn: Claim Disputes
PO Box 9040
Farmington, MO 63640-9040
If the complaint/grievance is related to claims payment, the provider must follow the process for claim reconsideration or claim dispute as noted in the Claims section of this Provider Manual prior to filing a Complaint.
Providers have three hundred sixty-five (365) calendar days from the date of payment/EOP, denial of a claim payment or services to file a written appeal/grievance/dispute. The provider grievance/dispute must be in writing, which can be mailed, faxed and/or emailed. Providers may consolidate complaints of multiple claims that involve the same or similar payment or coverage issues. Ambetter from Arizona Complete Health will send an acknowledgement letter to the provider within five (5) business days from the receipt of the provider grievance/dispute advising that The Plan has received their grievance/dispute and entered it into the grievance/dispute process.
Ambetter from Arizona Complete Health will provide a resolution with forty-five (45) calendar days from the date the appeal/grievance/dispute was received to make a decision and advise the provider of the decision.
Authorization and Coverage Complaints
Authorization and Coverage Appeals must follow the Appeal process below.
An Appeal is the mechanism which allows providers and/or members the right to appeal actions of Ambetter such as a prior authorization denial, or if the provider is aggrieved by any rule, policy or procedure or decision made by Ambetter. A provider has sixty (60) calendar days from Ambetter’s notice of action to file the appeal. The request for an appeal may be submitted verbally or in writing. Ambetter shall acknowledge receipt of each appeal within five (5) business days after receiving an appeal. Ambetter shall resolve each appeal and provide written notice of the appeal resolution, as expeditiously as the member’s health condition requires, but shall not exceed thirty (30) calendar days from the date Ambetter receives the appeal.
An Expedited Appeal the first step in the process is used when Ambetter from Arizona Complete Health has denied coverage for a medical service and the treating provider verifies that the time period for Formal Appeal process could cause a significant negative change in the insured’s medical condition. The Expedited Appeal can be initiated by mailing, phoning or faxing the request to the Ambetter from Arizona Complete Health and Grievances Department. Ambetter from Arizona Complete HealthAppeals and Grievances Department will oversee the processing of the appeal. Once Ambetter from Arizona Complete Health receives the necessary information, we will respond within 72 hours. We may overturn the original decision and approve specified medical services. We also may uphold the original denial. In that case, Ambetter from Arizona Complete Health will provide telephonic and written notification of the adverse decision to you and the member. Upon notification that the original denial was upheld, you may ask for the next level of review – the Expedited External Independent Review.
Providers may also invoke any remedies as determined in the Participating Provider Agreement.
Member Complaint/Grievance and Appeal Process
To ensure that Ambetter member’s rights are protected, all Ambetter members are entitled to a Complaint/Grievance and Appeals process. The procedures for filing a Complaint/Grievance or Appeal are outlined in the Ambetter member’s Evidence of Coverage.
The member may also access the How to File Grievances and Appeals Packet online (PDF).
If a member is displeased with any aspect of services rendered:
- The member should contact our Member Services department at 1-888-926-5057. The Member Services representative will assist the member.
- If the member continues to be dissatisfied, they may file a formal appeal/grievance. Again, our Member Services department is available to assist with this process.
- Depending on the nature of the complaint/grievance, the member will be offered the right to appeal our decision. At the conclusion of this formalized process, the member will receive written confirmation of the determination. Ambetter will complete the appeal process in the timeframes as specified in rules and regulation.
- The member has the right to appeal to an external independent review organization.
- A member may designate in writing to Ambetter that a provider is acting on behalf of the member regarding the complaint/grievance and appeal process.
The mailing address for non-claim related Member and Provider Complaints/Grievances and Appeals is:
Ambetter from Arizona Complete Health
P.O. Box 277610
Sacramento, CA 95827