Mandatory Passages and Language for MC+ Managed Care Health Plan Handbook, page 16

Grievances And Appeals

You may not always be happy with your health plan . We want to hear from you. Your health plan has people who can help you. Your health plan cannot take your benefits away because you make a grievance, appeal, or ask for a State Fair Hearing.

There are two (2) ways to tell your health plan about a problem:

Grievance Or Appeal

A Grievance is a way for you to show dissatisfaction about things like:

The quality of care or services you received;
The way you were treated by a provider; or
A disagreement you may have with a MC+ Managed Care health plan policy.

An Appeal is a way for you to ask for a review when your MC+ Managed Care health plan takes action to:

Deny or give a limited approval of a requested service;
Deny, reduce, suspend, or end a service already approved;
Deny payment for a service; or
Fail to act within required time frames for getting a service.

Your health plan must give you a written Notice of Action if any of these actions happen. The Notice of Action will tell you what we did and why and give you your rights to appeal or ask for a State Fair Hearing.

You Have Some Special Rights When Making A Grievance Or Appeal:

A qualified clinical professional will look at medical grievances or appeals.
If you do not speak or understand English, call your health plan to get help from someone who speaks your language.
You may ask anyone such as a family member, your minister, a friend, or an attorney to help you make a grievance or an appeal.
If your physical or mental health is in danger, a review will be done within 3 working days or sooner. This is called an expedited review. Call your health plan and tell them if you think you need an expedited review.
Your health plan may take up to 14 days longer to decide if you request the change of time or if we think it is in your best interest. If your health plan changes the time they must tell you in writing the reason for the delay.
If you have been getting medical care and your MC+ Managed Care health plan reduces, suspends, or ends the service, you can appeal. In order for medical care not to stop while you appeal the decision you must appeal within 10 days of receiving the written notice of action and tell them not to stop the service while you appeal. If you do not win your appeal you may have to pay for the medical care you got during this time.
You may request enrollment in another MC+ Managed Care health plan if the issue cannot be resolved.

How To Make A Grievance Or Appeal Or Ask For A State Fair Hearing:

GRIEVANCE — You may file a grievance on the telephone, in person, or in writing. Call your health plan to file a grievance.
- Your health plan will write you within 10 days and let you know they got your grievance.
- Your health plan must give written notice of a decision within 30 days.
APPEAL — You may file an appeal orally or in writing to your health plan. Unless you need an expedited review, you must complete a written request even if you filed orally.
- You must appeal within 90 days from the date of your health plan's Notice of Action.
- For help on how to make an appeal, call your health plan.
- Send your written appeal to your health plan
- Your health plan must write you within 10 days and let you know we got your appeal.
- Your health plan must give written notice of a decision within 45 days unless it is an expedited review.
STATE FAIR HEARING — You have the right to ask for a State Fair Hearing when your MC+ Managed Care health plan takes an action or when your appeal is not decided in your favor. You may ask for a State Fair Hearing orally or in writing. Unless you need an expedited review, you must complete a written request even if you asked orally.
- You must ask for a State Fair Hearing within 90 days from the date of the MC+ Managed Care health plan's written Notice of Action or Appeal Decision Letter.
- For help on how to ask for a State Fair Hearing, call the MO HealthNet Division at 1-800-392-2161.
- If you do not speak or understand English, call 1-800-392-2161 to get help from someone who speaks your language.
- You can send your written request to Participant Services Unit, MO HealthNet Division, P.O. Box 6500, Jefferson City, MO 65102-6500.
- You will be sent a form to complete. Once you send the form back, a date will be set for your hearing.
- You may ask anyone such as a family member, your minister, a friend, or an attorney to help you with a State Fair Hearing.
- A decision will be made within 90 days from the date you asked for a hearing.
- If your physical or mental health is in danger, a decision will be made within 3 working days. This is called an expedited hearing. Call 1-800-392-2161 if you think you need an expedited hearing.
- If you have been getting medical care and your MC+ Managed Care health plan reduces, suspends, or ends the service, you can ask for a State Fair Hearing. In order for medical care not to stop you must ask for a State Fair Hearing within 10 days of receiving the written notice of action and tell us not to stop the service while you appeal. If you do not win, you may have to pay for the medical care you got during this time.