Medicare Advantage Member Appeal/Grievance Procedures
An AZ Blue Medicare Advantage (MA) member may file a grievance or an appeal with AZ Blue in writing or by calling Member Services. A member may appoint any individual, such as a relative, friend, advocate, an attorney, or a healthcare provider to act as his or her representative.
A provider may not charge a member for representation in filing a grievance or appeal. Administrative costs incurred by a representative during the appeals process are not considered reimbursable.
Appointment of an authorized representative
To be appointed as an authorized representative for an MA member, both the member making the appointment and the representative accepting the appointment (including attorneys) must sign, date, and complete a representative form. Members may appoint a representative using the CMS Appointment of Representative form (CMS-1696), available from the CMS Forms List. Alternatively, a legal representative may be authorized by the court or, in accordance with state law, to act on behalf of a member. This type of appointment could include, but is not limited to, a court-appointed guardian, or an individual who has durable power of attorney for the member.
A signed Appointment of Representative form or other proof of legal representative status is required when a representative files a grievance or appeal on behalf of an AZ Blue MA member. Per CMS guidance, a signed appointment form is valid for the grievance or appeal at hand for up to one year from the date the form is signed by both the member and the representative, unless the member indicates a shorter time frame, or revokes the appointment.
When an appointment of representative document is required, AZ Blue will not begin a grievance or appeal review until or unless all appropriate documents are received. The time frame for processing a grievance or appeal request begins when we receive the appropriate documentation. If we don’t receive the appointment documentation or other requested documentation within a reasonable period of time, the grievance or appeal will be dismissed on the grounds that a valid request was not received.
MA MEMBER GRIEVANCES (complaints)
A member (or authorized representative) may file a grievance to convey the member’s dissatisfaction with AZ Blue or a contracted provider, regardless of whether remedial actions are possible. Grievances may include concerns about:
- Operational issues such as long wait times, difficulty getting through to the health plan or a provider on the phone
- Benefits package
- Access to care
- Customer service
- Quality of care
- Interpersonal aspects of care (e.g., the demeanor of healthcare personnel or rudeness or disrespect to members)
- Adequacy of facilities
Filing an MA member grievance
An MA member (or authorized representative) may file a grievance orally or in writing within 60 calendar days after the date the event occurred. A grievance must include a complete description of the issue including details such as date and time of the event causing the member’s dissatisfaction, the location of the event, the name(s) of the people (e.g., service provider, employee, or agent) who were involved in or witnessed the event, and what circ*mstances caused the dissatisfaction (e.g., concerns regarding access to services, the quality of care, benefit package, aspects of health plan or provider operations or staff).
A member (or authorized representative) can call or send a written grievance to the AZ Blue MA Grievance and Appeals Department at:
P.O. Box 29234
Phoenix, AZ 85038-9234
Phone: 1-800-446-8331 (TTY 711)
Fax: 602-544-5656
All grievance requests are acknowledged in writing to the member (or authorized representative).
MA member grievance review process
The MA Grievance and Appeals Department conducts an investigation concerning the member’s grievance. During this process, we will contact any providers or departments related to the member’s grievance, address the grievance as quickly as possible, and respond to the member (or authorized representative) verbally or in writing no later than 30 calendar days after receiving the grievance. We may extend the time frame by up to 14 calendar days if the member requests an extension or if we justify a need for additional time and the delay is in the member’s best interest. If the member has filed an expedited grievance (based on CMS criteria), we will respond to the member (or authorized representative) within 24 hours.
Providers must comply with AZ Blue investigation efforts in a timely manner so that the CMS timelines for processing member grievances can be met.
MA MEMBER APPEALS (requests for reconsideration)
A member (or authorized representative) has the right to file an appeal to request reconsideration of an adverse decision made by AZ Blue. Appeals may be filed about:
- A decision to deny or delay in providing, arranging for, or approving healthcare services
- A disagreement about the cost-share amount assigned by the Plan to the member
Member appeal procedures include reconsideration/redetermination by AZ Blue and may also include, under certain escalated circ*mstances, reconsideration by an independent review entity (IRE), a hearing before administrative law judges (ALJs), review by the Medicare Appeals Council, and a judicial review.
Filing an MA member appeal
According to CMS guidance, an MA member (or authorized representative) may file an appeal orally or in writing within 60 calendar days from the date of a denial notice. If the appeal is filed beyond the 60 calendar-day time frame and good cause is not provided, we will dismiss the case. All member appeals (requests for reconsideration/redetermination) are acknowledged in writing to the member and the authorized representative; or directly to the legal representative.
An appeal should include an explanation of why the original decision should be reconsidered, along with relevant documents, such as a copy of the adverse organization determination (denial), medical records, and any other documentation that support the appeal.
A member (or authorized representative) can call or send a written request for appeal/reconsideration to the AZ Blue MA Grievance and Appeals Department at:
AZ Blue Medicare Advantage Grievance and Appeals Department
P.O. Box 29234
Phoenix, AZ 85038-9234
Phone: 1-800-446-8331 (TTY 711)
Fax (Expedited Pre-Service Appeal): 602-544-5655
Fax (Standard Pre-Service Appeal): 602-544-5656
Fax (Part D Appeals): 602-544-5657
Fax (Payment /Non-Par Appeals): 602-544-5658
Typical review process for MA member Part C appeals
AZ Blue has 30 calendar days to process a standard appeal for medical services that have not yet been provided, and 60 calendar days to process an appeal for reimbursem*nt/payment for services that have already been provided. As part of this process, we will make every effort to obtain all necessary medical records and other information before making a decision. The member (or authorized representative) will be notified in writing of the decision and any additional rights available within the allowed time frame.
f the member, the member’s representative, or a treating provider requests an expedited appeal for medical services not yet provided, we will make a decision within 72 hours of the request. In certain situations, if it is in the member’s best interest, an extension of up to 14 days may be taken. The member (or authorized representative) will be notified orally of the decision, followed by a written notice within three calendar days of the oral notice. If the expedited appeal request does not meet criteria to be processed as expedited, it will be changed to a standard appeal time frame. The member (or authorized representative) will be notified in writing of this change and of the right to file an expedited grievance about the decision.
Review process for standard MA pre-service appeals related to Part D prescription drugs
AZ Blue has seven calendar days to process a request for a standard pre-service redetermination regarding Part B and D prescription drugs. During this process, we will make every effort to obtain all necessary records and other information before making a decision. The member (or authorized representative) will be notified in writing of the decision and any additional appeal rights within the allowed time frame.
If AZ Blue approves a request to expedite a redetermination of a Part D prescription drug, a decision will be made within 72 hours of the request. The member (or authorized representative) will be notified in writing of the final decision. If a request to expedite a redetermination does not indicate that the member’s life, health, or ability to regain maximum function could be jeopardized, we may transfer the request to the standard redetermination process. The member (or authorized representative) will be notified in writing within three calendar days of the decision to apply the standard redetermination process and the right to file an expedited grievance about the decision.
