Grievances & Appeals


Appeals

Appeal and Request for Fair Hearing

WHAT IF YOU DISAGREE WITH A DENIED SERVICE?

If you are dissatisfied with denial of services by UFC you may file an “appeal”. An appeal must be filed in writing within 60 days from receipt of UFC’s Notice of Adverse Benefit Determination letter.


WHO MAY FILE AN APPEAL?

You, as the enrollee, may file an appeal. An enrollee representative, a legal representative of a deceased enrollee’s estate, or a provider acting on behalf of an enrollee, and with the enrollee’s written consent, may file an appeal.

WHAT CAN YOU FILE AN APPEAL FOR?

The reasons you may file an appeal are:

  • Denial or limited authorization of a requested service, including the type or level of service
  • Reduction, suspension, or termination of a previously authorized service
  • Denial, in whole or in part, of payment for a service
  • Failure to provide services in a timely manner
  • Failure to act within the timeframe required for standard and expedited resolution of appeals and standard disposition of grievances
  • The denial of a rural enrollee’s request to obtain services outside the contractor’s network under 42CFR 438.52 (b)(2)(ii), when the contractor is the only contractor in the rural area

HOW DO YOU FILE AN APPEAL?

Appeals may be requested by telephone or in writing. You may call and ask to speak to an Appeals representative to file an appeal or you can mail or fax the Grievance & Appeals Department. UFC will provide you with a written decision within 30 days of filing the appeal.

Additionally, the timeframes for standard and expedited appeals may be extended up to 14 days if you request an extension or if we establish a need for an extension when the delay is in your best interest.

HOW DO YOU REQUEST A STATE FAIR HEARING?

If you are not satisfied with the appeal decision, you may file a request for State Fair Hearing with UFC. This request must be made in writing to UFC within 30 days of the date of receipt of the appeal decision. You can mail or fax your request. UFC will send your appeal file to AHCCCS and a hearing date will be scheduled for you to attend. AHCCCS Administration will decide if UFC’s decision was correct. If AHCCCS decides that UFC’s decision was incorrect, UFC will authorize and pay for services. Additionally, there are Legal Services Programs in your area that may be able to help you with the hearing process. General legal information about your rights can also be found on the internet at the following website: www.azlawhelp.org.

WHAT IS AN EXPEDITED APPEAL?

You may file an expedited appeal, or it may be filed on your behalf by your provider if you need a decision more quickly than 30 days. An expedited appeal will be approved if UFC determines that the time to process a standard appeal would seriously jeopardize your health, life or ability to attain, maintain or regain maximum function. If an expedited appeal request is not approved, UFC will notify you within 24 hours and transfer the appeal to the 30-day timeframe for a standard appeal. If we agree to accept your request for an expedited appeal, UFC will make a decision in 3 working days.

IF YOU ARE CURRENTLY RECEIVING THE SERVICES REQUESTED, CAN YOU CONTINUE TO RECEIVE THEM DURING THE APPEAL PROCESS?

Yes, but the request must be in writing and must be received by UFC within 10 days of the receipt of the Notice of Adverse Benefit Determination letter. However, you may be responsible for payment of those services if UFC or a State Fair hearing decision upholds the denial.

APPEAL PROCESS FOR MEMBERS WHO HAVE BEEN DETERMINED TO HAVE A SERIOUS MENTAL ILLNESS (SMI)

If a member disagrees with their SMI determination, they have the right to appeal the decision, including:

  • Initial eligibility for SMI services;
  • Decisions regarding fees or waivers;
  • The assessment report;
  • Service plans;
  • Treatment plans;
  • Discharge plans;
  • Decisions regarding services funded through Non-Title 19/21 funds;
  • Capacity to make decisions, need for guardianship, or other protective services or needs for special assistance;
  • Decisions regarding the loss of eligibility for SMI services; and/ or
  • A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the member.

SMI APPEAL TIMELINES:

UFC will send the member a written notice within five business days of when the request for an appeal was received.

UFC will have an informal conference with the member, their legal guardian, or authorized representative within seven business days of when the appeal was received.

UFC will notify the member of the time and location of the conference, in writing, at least two days prior to the date of the conference. If the member cannot come to the conference, they can request that the conference be conducted over the phone.

If the member is satisfied with the resolution of the issue at the informal conference with UFC, they will receive a written notice that summarizes the appeal, the resolution, and the date of when the resolution will be implemented.

If a resolution is not reached at the informal grievance with UFC, and if the appeal is not related to the member’s eligibility for behavioral health services, then an informal conference will be held with AHCCCS within 15 business days of when the appeal was received. The informal conference with AHCCCS is not required and the member can request to skip the second conference.

If a resolution is still not reached at the informal conference with AHCCCS, or if the member chose to skip the informal conference with AHCCCS, then the member will be provided with information on how to request an Administrative Hearing through the AHCCCS office of Behavioral Health Grievance and Appeals.

SMI EXPEDITED APPEAL TIMELINES:

Members who need an appeal to be expedited will receive a written notice from UFC within one business day of when the expedited appeal was received.

UFC will have an informal conference with the member, their legal guardian, or authorized representative within two business days of when the expedited appeal was received.

If the member is satisfied with the resolution of the issue at the informal conference with UFC, they will receive a written notice that summarizes the expedited appeal, the resolution, and the date of when the resolution will be implemented.

If a resolution is not reached at the informal conference with UFC, and if the expedited appeal is not related to the member’s eligibility for behavioral health services, then an informal conference will be held with AHCCCS within two business days of when the expedited appeal was received. The informal conference with AHCCCS is not required and the member can request to skip the second conference.

If a resolution is still not reached at the informal conference with AHCCCS, or if the member chose to skip the informal conference with AHCCCS, then the member will be provided with information on how to request an Administrative Hearing through the AHCCCS office of Behavioral Health Grievance and Appeals.

CONTINUING SERVICES DURING THE APPEAL PROCESS

Members can continue to receive services they were already receiving unless a qualified provider decides that reducing or stopping services is best for the member, or if the member agrees, in writing, to reduce or terminate services. If the appeal is not decided in the member’s favor they may be required to pay for the services they received during the appeal process. 

Contact information for Grievance & Appeals

University Family Care

Attn: Grievance & Appeals Department

2701 E. Elvira Road

Tucson, AZ 85756

Phone: (800) 582-8686, ask for Grievance & Appeals

Fax: (520) 874-3462 or (866) 465-8340


Grievances

WHAT IF YOU HAVE QUESTIONS, PROBLEMS OR COMPLAINTS ABOUT UFC?

Call Customer Care if you have a specific grievance or dissatisfaction with any aspect of your care. Examples of grievances are: service issues, transportation issues, quality of care issues and provider office issues. Interpretation services are available in any language at no cost to you. You may call Customer Care to file a grievance (complaint). You may also file your grievance in writing by mailing it to the address listed above. Your grievance will be reviewed and a response will be provided no later than ninety (90) days from the date that you contact us at (800) 582-8686.

If UFC denies a requested service, you will receive a letter called the Notice of Adverse Benefit Determination.


SMI Grievance and Request for Investigation Process

If you are have been determined to have a Serious Mental Illness (SMI) and feel that your rights have been violated, you have the right to file a grievance and request an investigation.

Members, their legal guardians, or authorized representatives can file a SMI grievance and request an investigation if:

  • They are an adult who has been determined to have a SMI.
  • If the services received by the member are behavioral health services.
  • The member believes their rights have been violated;
  • The member believes they have been abused or mistreated by a provider or their staff; or
  • The member believes that they have been subjected to illegal, dangerous, or inhumane treatment.

Members, their legal guardians, or authorized representatives have 12 months from the time their rights were violated to file an SMI grievance and request an investigation. SMI Grievances and requests for an investigation can be filed orally or in writing to:

The University of Arizona Health Plans

Attention: Grievance and Appeals

2701 East Elvira Road

Tucson, AZ 85653

Forms to file an SMI Grievance and request for an investigation are available at the above address or at any contracted behavioral health provider.

Once a member’s SMI Grievance and request for an investigation is received, UFC will respond in writing within five days and will explain how the grievance and request for an investigation will be handled.

Grievances and requests for investigations regarding physical or sexual abuse, or death should be reported directly to AHCCCS at:

Phone: (602) 417-4000

Fax: (602) 252-6536

In-State Toll Free: (800) 654-8713 (Outside Maricopa County)

Out-of-State Toll Free: (800) 523-0231

For the Hearing Impaired: Arizona Relay 711

Mail: AHCCCS

Attention: Behavioral Health Grievance and Appeals

801 E Jefferson St. Phoenix, AZ 85034 


Member Rights & Responsibilities

OUR COMMITMENT TO YOU

Our goal is to provide high-quality medical care and advanced medical treatment. We also promise to listen, treat you with respect, and understand your individual needs. Members have rights and responsibilities. The following is a description of your rights and responsibilities.


MEMBER RIGHTS

  1. You will receive care that meets your needs in a way that doesn’t judge race, gender, religious beliefs, values, language, how much a person is able to do, age, physical or mental disability, or ability to pay
  2. You will be treated with respect and with due consideration for his or her dignity and privacy. We understand your need for privacy and confidentiality including protection of any information that identifies you
  3. You will be treated in a safe, supportive and smoke-free environment
  4. You have the right to information about UFC’s services, health care providers, admission, transfer, discharge, billing policies, and members’ rights and responsibilities
  5. You have the right to choose your primary care physician within the UFC network
  6. UFC and their participating providers will safeguard the confidentiality of your information as required by state and federal law, including your UFC specific record set and your medical (care) records kept by your provider(s).

UFC specific record set: The law states that you have the right to read or get copies of your medical claim history, pharmacy claim history, grievance and appeals documents, and your UFC phone call records at no cost to you from UFC. To receive those records, UFC must have the request in writing. You may make this request by calling our Customer Care Center. You will be sent an authorization form to complete and will return it to the Compliance Department with a copy of a picture ID so we can make sure we only send your records to you or someone you allow to receive your records. You can receive your records in paper form or by email (encrypted or not) if you prefer.

UFC must reply to your request for medical records no later than thirty (30) days after receipt of your request. If UFC is unable to take action within 30 days, UFC may take any additional 30 days provided UFC lets you know the reason for the delay and the date the request will be completed. This response will either be a copy of your records in the manner you requested, permission for you to view your records on-site, or a reason for denying your request. If a request is denied, in whole or in part, UFC must give you the reason for the denial and your rights to a review of the denial of access.

MEDICAL CARE RECORDS

The law states that you have the right to read, or annually request and receive a copy of your medical care records at no cost to you (from any provider who provides care for you ). Contact your provider to ask to see or get a copy of your medical record. You will receive a response to your request within 30 days. However, your right to access medical care records may be denied if the information is psychotherapy notes, compiled for, or in a reasonable anticipation of a civil, criminal or administrative action, protected health information subject to the Federal Clinical Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR 493.3(a)(2), or a licensed health care professional has determined that receiving or accessing your records would likely endanger the life or safety of you or another person. If your access is denied for some of these reasons, you have the right to have the denial reviewed.

  1. You have the right to request to have any provider who provides care for you amend or correct your medical care records that are kept by your treating provider. You may initiate this request by calling our Customer Care Center and your response will be required in writing.
  2. You have the right to help in decision making about your health care and Advance Directives (decisions about what kind of care you would like to receive if you become unable to make medical decisions)
  3. You have the right to complain to us about UFC and/or care provided
  4. You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation
  5. Your wishes are important. You have the right to the information needed to help you make informed decisions. Here is a list of some, but not all of your rights:
  6. You can accept or refuse any treatment pursuant to 42 C.F.R.
  7. You will be informed of any consequences of refusing treatment (438.100)
  8. You can receive information on available treatment options and alternatives in a manner that is appropriate to your condition and is easy to understand
  9. You can make Advance Directives and appoint someone to make health care decisions for you. You or your representative can change your Advance Directives at any time
  10. You or someone who represents you can take part in resolving problems about your health care decisions
  11. You have the right to the following:
  12. You can be told about Physician Incentive Plans that affect referral servicesYou have the right to know that UFC is required to participate in a stop-loss insurance program
  13. You can be told the types of plans UFC uses for compensation
  14. You can get a summary of member survey results
  15. You have the right to have language interpretive services from a provider who speaks your primary language, if other than English
  16. You have the right to have a list of available PCPs, including those who speak a language other than English and access to a sign language interpreter for the hearing impaired
  17. You have the right to written materials in alternate formats
  18. You have the right to a second opinion from a qualified health care professional within UFC’s network. If an in-network second opinion is not available, you have the right to have a second opinion arranged outside of the UFC network at no cost to you
  19. You have the right to request a copy of the Notice of Privacy Practices at no cost to you. The notice describes UFC’s privacy practices and how we use health information about you and when we may share that health information with others
  20. You have the right to request the criteria that decisions are based on American Indian members are able to receive health care services from any Indian Health Service provider or tribally owned and/or operated facility at any time
  21. You have the right to request information on the structure and operation of University Family Care or its subcontractors
  22. You have the right to get another caregiver for “critical services” within two hours. The term “critical services” includes certain tasks. The tasks may include taking a bath, using the toilet, dressing and eating. Help moving to or from a bed or wheelchair is included. Help with other similar daily tasks may be included.

MEMBER RESPONSIBILITIES

  1. It is your responsibility to provide, to the best of your knowledge, information to help the UFC staff care for you
  2. It is your responsibility to follow instructions and guidelines given by those providing health care
  3. It is your responsibility to know the name of your assigned PCP
  4. It is your and your family members’ responsibility to be considerate of the rights and property of patients and staff. This includes smoking and visitation policies
  5. It is your responsibility to protect your member ID card. Do not lose it or share it with anyone
  6. It is your responsibility to pay your co-payments for care received as soon as possible
  7. It is your responsibility to schedule appointments during medical office hours whenever possible before using urgent care facilities and/or emergency rooms
  8. It is your responsibility to give your PCP all the facts about your health problems: past illnesses, hospital stays, all medications, shots and other health concerns. Let your PCP and/or your case manager know about any changes in your condition
  9. It is your responsibility to report changes that could affect your eligibility such as address, telephone number and/or assets
  10. It is your responsibility to arrive on time and to let the medical office know in advance when you can’t keep an appointment
  11. It is your responsibility to bring immunization records to every appointment for children ages 18 and younger
  12. It is your responsibility to watch over children with you at all times
  13. It is your responsibility to cancel your ride when you cancel your appointment
  14. It is your responsibility to NOT behave in a way that disrupts and/or does not allow a doctor to serve you or another patient in a safe way
  15. It is your responsibility to provide information requested to verify your account. This includes your name, birth date, ID number, phone number, and address.