Appeals & Actions

What is an appeal?

An appeal is a request from a member to reconsider or change a decision or action.

What is an action?

An “action” by Mercy Care Plan means:

• Denial or reduction of a service you or your doctor have asked for
• Reduction, suspension or termination of a service you currently have
• Refusing to pay for either part or all of a service
• Not providing services in a timely manner
• Not acting within certain timeframes for complaints and appeals
• Refusing the request of a member living in a rural area to get services out of the network when MCP is the only local health plan

What happens if my services are refused?

The Appeals Department will review your appeal and send a decision in writing to you within 30 days. The letter will tell you what Mercy Care Plan’s decision was and the reason for the decision. If Mercy Care Plan denies your appeal, you may then request a fair hearing with AHCCCS by following the steps in our decision letter to you.

What happens if my services are cut back, delayed or ended?

If your services are reduced, delayed or stopped, we will write to you at least 10 days before the change to let you know.

Notice of Action

If Mercy Care Plan decides that the service you requested cannot be approved, or if a service is reduced, suspended or ended, you will get a "Notice of Action" which will tell you:

• What action was taken and the reason for it
• Your right to file an appeal and how to do it
• Your right to ask for a fair hearing with AHCCCS and how to do it
• Your right to ask for a expedited resolution and how to do it
• Your right to ask that your benefits be continued during your appeal, how to do it and when you may have to pay the costs for the services

How do I appeal an action or decision?

If you don’t agree with Mercy Care Plan’s decision, you may appeal in writing or by phone. An interpreter is available if you need one. You may appeal within 60 days from the date your service was refused, delayed, cut back or ended. To file an appeal, you (or someone you give written permission to) must call or send a letter to:

Mercy Care Plan
Appeals Department
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
(602) 263-3000 or (800) 624-3879

How long will it take to answer my appeal?

When Mercy Care Plan receives your appeal, we will send you a letter within five days telling you that we received it. We’ll let you know if we need more details in person or in writing. If you want your care to continue while your appeal is reviewed, you must file your appeal within 10 days from the date of Mercy Care Plan’s Notice of Action letter to you.

The Appeals Department will look at your appeal and send a letter to you within 30 days. The letter will tell you Mercy Care Plan’s decision and the reason for the decision.

What happens if my appeal is not accepted?

If Mercy Care Plan does not accept your appeal, you may then request a fair hearing with AHCCCS by following the steps in our decision letter to you. If you request a hearing, you will receive information from AHCCCS about what to do. Mercy Care Plan will give its file and records to the AHCCCS Office of Legal Assistance.

If your appeal is denied at this point, you might have to pay for services you received while it was being looked at. If your appeal is accepted, the Plan will approve and provide your services.

What if I’m enrolled in DD?

If you or a family member are signed up with DD and want to appeal a decision, you may do so. Your appeal must be filed within 60 days of the decision. You file your appeal by phone at (602) 542-0419 or (800) 624-4964 or mail your appeal to:

Department of Economic Security
Division of Developmental Disabilities
Compliance and Review Unit, Site Code 791A
1789 W. Jefferson, 4th Floor
Phoenix, AZ 85007

The Division of Developmental Disabilities Compliance and Review Unit will look into your appeal and make a decision. You will receive a letter telling you the decision and the reason for the decision. It will also tell you how to request a fair hearing with AHCCCS if you are still not satisfied.

How can I request an expedited review of my appeal?

• Write or call MCP at the address or number listed above.
• File your appeal within 60 days of the date of your notification letter.
• Ask that Mercy Care Plan review it within three days.

If you want your services to continue during your appeal, file your request within 10 days of the date of the letter from MCP. DD members should file this request with Mercy Care Plan.

What happens if my request for a faster review is refused?

If Mercy Care Plan decides not to review your appeal faster, you will get an answer in 30 days. If MCP refuses your request for services, you can ask for a fair hearing with AHCCCS. Simply follow the steps in your decision letter.

If your appeal is refused, you might have to pay for services you got while your appeal was being looked at.