Complaints, SMI Grievances and Appeals

Health Choice Integrated Care (HCIC) wants you to be happy with your service. If you are not happy with the care you are receiving, you have the right to contact us to let us know.

You can find more information about filing a grievance, Serious Mentally Ill (SMI) grievance or an appeal in our Member Handbook.

For the Appeal or SMI Grievance Form you may download it here.

A Grievance is a documented statement that you are not happy with any aspect of your care. Reasons for complaints could include such things as:

  • The quality of care or services you received.
  • A disagreement with the denial to process an appeal as expedited.
  • The failure of a provider to respect a person’s rights.
  • A provider or employee of a provider being rude to you.

You can call or write to HCIC’s Member Services to file a Grievance. To call, dial 1-800-640-2123; TTY/TDD call 711 or 1-800-364-8939.

If you would like to mail in your complaint, please send it to:

Health Choice Integrated Care

 Member Services Department

1300 South Yale Street

Flagstaff, AZ, 86001

 

An SMI Grievance is when you feel like a provider has treated you unfairly or violated your SMI rights. Our Grievance and Appeals Department will investigate your case further for you.

SMI Grievances may only be filed by or on behalf of adult persons who have been determined with a Serious Mental Illness (SMI). The SMI Grievance must be regarding a behavioral health service that was received by the member.

 

You can file an SMI Grievance if you feel:

  • Your rights have been violated;
  • You have been abused or mistreated by staff of a provider; or
  • You have been subjected to a dangerous, illegal, or inhumane treatment environment.

 

You may file an SMI Grievance by calling or writing the HCIC Grievance and Appeals Department. To call dial 1-800-640-2123; TTY/TDD call 711 or 1-800-364-8939.

 

If you would like to mail in your Grievance, please send it to:

Health Choice Integrated Care

 Grievance and Appeals Department

1300 South Yale Street

Flagstaff, AZ, 86001

 

An appeal is a formal request to review an action or decision related to your behavioral health services.

There are 3 types of appeals depending on what is being appealed and who is filing the appeal. The 3 types of appeals are:

  • Appeals for Title XIX/XXI AHCCCS eligible members
  • Appeals for members determined to have a SMI
  • Appeals for members who are not enrolled as a person with SMI and are Non-Title XIX/XXI eligible

 

How do I file an appeal?

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.

 

You may file an appeal by calling or writing. To call, dial 1-800-640-2123; TTY/TDD call 711 or 1-800-364-8939. To file a written appeal, mail the appeal to:

Health Choice Integrated Care

 Grievance and Appeals Department

1300 South Yale Street

Flagstaff, AZ, 86001

 

If you are Title XIX/XXI AHCCCS eligible, you have the right to ask for a review of the following actions:

  • 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.
You may appeal decisions about your treatment and denials of services. The reasons for filing an appeal can be found in ACOM Policy 444. You can also refer to the HCIC Member Handbook. This appeal requires HCIC to hold an informal meeting with you to try to resolve your appeal.

If you are Non-Title XIX/XXI (AHCCCS) eligible and not determined to have SMI, you may appeal actions or decisions related to decisions about behavioral health services you need that are available through HCIC.

 

If you file an appeal you will continue to get any services you were already getting unless:

  • A qualified clinician decides that reducing or;
  • Terminating services is best for you or;
  • You agree in writing to reducing or terminating services

If the appeal is not decided in your favor, Health Choice Integrated Care may require you to pay for the services you received during the appeal process.

You must ask for a State Fair Hearing in writing within 30 days of getting the Notice of Appeal Resolution. Requests for State Fair Hearings should be mailed to:

Health Choice Integrated Care

 Grievance and Appeals Department

1300 South Yale Street

Flagstaff, AZ, 86001

YOU HAVE THE RIGHT TO HAVE A REPRESENTATIVE OF YOUR CHOICE TO ASSIST YOU AT THE STATE FAIR HEARING.