If you are not happy with any health care you received, you have the right to file a grievance. You can also file a grievance about  Blue Cross Blue Shield of Arizona Health Choice. This gives you a chance to tell us about your concerns.

You can file a grievance about issues related to your health care such as:

• Timeliness
• Whether care of treatment is appropriate
• Access to care
• Quality of care
• Staff attitude
• Rudeness
• Any other kind of problem you may have had with your health care service

You can file a grievance either over the phone or in writing.

To file a grievance by phone:

• Call Member Services and we will help you.
• The representative will ask you about the concern. This will help us get all of the information necessary to address your matter.
• Tell the representative the date the problem happened and any other facts about the issue.

To file a grievance in writing, send a letter to:

Blue Cross Blue Shield of Arizona Health Choice
Attn: HC Member Grievances
PO Box 52033
Phoenix, AZ 85072

We will carefully look into your concern. We are here to help you. We may contact you for more information or talk to others involved in your care. Once the review is complete, we will send you a letter telling you the outcome.

You also have the right to contact the AHCCCS Medical Management Department if you feel that we have not resolved your concerns about the adequacy of a Notice of Action letter. The AHCCCS Medical Management Department can be reached by phone at 602-417-4000 or in writing at AHCCCS Attn: Medical Management Department, 801 E. Jefferson Street, Phoenix, AZ 85034.

We are committed to providing high-quality care for our members.

• We review all requests for services using evidence-based medical data
• Our decisions are based on the appropriateness of care and medical necessity

Providers or other health care professionals are not financially rewarded based on denial of care or for limiting services.
If you have any questions or concerns about covered services, please contact Member Services for help.

We may deny services that your doctor asks for, or we may limit or stop your care. If this happens, you will get a letter from us. This is called a Notice of Adverse Benefit Determination.

The Notice of Adverse Benefit Determination will explain the decision and why we made it. It will tell you the law, rule or policy that was used to make the decision. It will give you the date the decision was made.

The Notice of Adverse Benefit Determination will explain how to ask for a second review if you do not agree with our decision. The Notice of Adverse Benefit Determination letter will tell you how to continue services during the appeal process. This review is called an appeal. We will tell you how to continue getting services during the appeal process.

The Notice of Adverse Benefit Determination will also explain that if you lose the appeal, you will have to pay for care you got during the appeals process. Before you file an appeal, check with your doctor. Your doctor could have a different plan of care that may be covered. The care plan may include other treatment you can get that will have the same result for you.

If you disagree with the Notice of Adverse Benefit Determination, you can request an appeal. You can ask for an appeal by calling Member Services, or by writing a letter to us.

To file an appeal by phone:

• Call Member Services at 800-322-8670 (TTY 711) and a representative will help you.
• Have your Notice of Adverse Benefit Determination letter with you when you call. This will help us get all of the information necessary to address your matter.

To file an appeal in writing:

• Your appeal letter must be sent directly to us.
• Do not send your appeal to AHCCCS.
• Mail your letter to: Blue Cross Blue Shield of Arizona Health Choice, Attn: Member Appeals, PO Box 52033, Phoenix, AZ 85072

You have 60 calendar days from the date of the Notice of Adverse Benefit Determination or the date of any adverse action to file your Appeal. We will send you a letter stating we received your request. This will be sent to you within five working days.

You may ask to look at the information we are reviewing to make our decision. You may ask to see records at any time during the Appeal process. We will provide a copy of the law, rule or policy used to make the decision if you request it. All requested information will be provided at no cost to you. You can also send us written documents or other information if you think it will help us with our review. This includes having us talk to people involved in your care, such as another provider or family member.

You can have anyone you choose to help you appeal: your practitioner, other health care practitioner, guardian/representative, attorney, or other representative can appeal for you. If you want someone to help, you will need to write us giving them permission. If you would like legal help with this decision, you can contact the legal aid program in your county. There is a list of programs in Attachment B, Legal Services Program. You can also contact the State Protection and Advocacy System, the Arizona Center for Disability Law, at 1-800-927-2260. Persons determined to have a Serious Mental Illness (SMI) may also ask for help by contacting an Advocate at the AHCCCS Office of Human Rights at 1-800-421-2124 or 602-364-4585.

We will have someone review your file who had nothing to do with your first Notice of Adverse Benefit Determination that denied, limited or stopped care we said you could have. We will make a decision about your appeal within 30 calendar days.

After we review your appeal, we will send you a letter to tell you our decision. This letter is called a Letter of Appeal Resolution. If you have not received written notice within 5-7 business days after the 30 calendar day timeframe, you may file a State Fair Hearing using the process as specified in this section.

If you cannot wait 30 calendar days for a decision, you can ask us to make a decision faster. You can ask for a faster decision if waiting 30 calendar days could cause serious harm to your health, life or your ability to reach, get back to or keep functioning at a maximum level. This is called an Expedited Appeal.

The Expedited Appeal process follows the same steps as a standard appeal, except the decision is made in 72 hours, rather than 30 days.

We will call to tell you our Appeal decision. You will also receive a Notice of Expedited Appeal Resolution letter. This letter will tell you our decision. If we do not agree that an expedited decision has to be made, then we will write to you within two days. We will also try to call you. We will still make a decision within 30 calendar days.

You will receive a Notice of Appeal Resolution Letter, which will tell you our decision.

If you have not received written notice within 5-7 business days after the 72-hour timeframe, you may file a State Fair Hearing using the process as specified in this section.

If you choose to appeal the Notice of Adverse Benefit Determination, you have the right to get help. You can file the appeal yourself or you can have someone file it for you. The person helping you is called your “representative.”

A representative may be a family member, a provider, or an attorney if you wish. The process is the same whether you file the appeal yourself or have someone help you. The time frame is also the same in either case.

When we send you the Notice of Adverse Benefit Determination, we also send a list of agencies that may help you file your appeal. If you need another list, please call Member Services. You can also get help filing your appeal from a family member, friend, clergy, or even your doctor.

If you would like to use a representative, please fill out this Appointment of Representative (AOR) form and mail to:
Blue Cross Blue Shield of Arizona Health Choice
Attn: HC Member Appeals
PO Box 52033
Phoenix, AZ 85072

• Appointment of Representative – English
• Appointment of Representative – Spanish

If you do not like the appeal decision made by us, you have the right to request a hearing. This is called a State Fair Hearing. Information about how to ask for a state fair hearing will be included in the Notice of Appeal Resolution (or the Notice of Expedited Appeal Resolution) letter. The State Fair Hearing process offers a chance to have your request heard by an Administrative Law Judge. You must ask for the State Fair Hearing in writing. You have 30 days from the date you receive the Notice of Appeal Resolution (or Notice of Expedited Appeal Resolution) letter to ask for a State Fair Hearing.

To ask for a State Fair Hearing in writing, send a letter to:

Blue Cross Blue Shield of Arizona Health Choice
Attn: HC Member Appeals
PO Box 52033
Phoenix, AZ 85072

To learn more about appeals, view the Member Handbook here.