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Appeals and grievances

As a member, you have the right to ask us to reconsider decisions we have made and to make grievances. These are called appeals and grievances.

Appeals

If you disagree with our decision about your care or services you requested, you can file an appeal. An appeal is a formal way of asking us to review and change a coverage decision we made.

You can file an appeal orally or in writing to your MO HealthNet Managed Care health plan, Healthy Blue. You can present your case in person if you want. You can represent yourself or a provider or other authorized representative such as a relative, a friend, or anyone else you want can help you with your okay in writing. Healthy Blue also allows an attorney to represent you.

You have 60 calendar days after you get a written notice from us to file an appeal. Healthy Blue must make a decision on your appeal within thirty (30) calendar days of receiving it. If your appeal review needs to be expedited (reviewed more quickly than the standard time frame) because you have an immediate need for health services, call Member Services at 833-388 -1407 (TTY 711) and tell us what might happen if you don’t get a quick decision. The expedited review must be completed within seventy-two (72) hours.

You can file an appeal by mail or phone:

Mail:
P.O. Box 62429
Virginia Beach, VA 23466

Phone:
Call at 833-388-1407 (TTY 711)

You can also send us an appeal by filling out a Member Appeal Request Form and sending it to us. The Member Appeal Request Form can also be used if someone is submitting the appeal for you. We need your written consent to have someone submit an appeal for you.

Before and during the appeal, you or your representative can see your case file, including medical records and any other documents and records being used to make a decision on your case, at no cost to you.

You can ask questions and give any information (including new medical documents from your providers) that you think will help us to approve your request. You may do that in person, in writing or by phone.

If you need help with understanding the Appeals process, you can call Member Services at 833-388-1407 (TTY 711).

Standard appeals:
If we have all the information we need, we will tell you our decision in writing within 30 calendar days.

Expedited (fast track) appeals:
If we have all the information we need, we will call you and send you a written notice of our decision within 72 hours of receiving your request.

Appeals extensions:
We can ask for 14 more calendar days if we need extra time. We’ll send you a letter within two calendar days telling you why more time is needed. You may file a grievance if you’re unhappy with our request for 14 more days to complete our review.

You may also ask for 14 more days if you need more time. Upon receipt of your appeal request, you also have access to a copy of your appeal case file at no cost.

If you need more time to gather your documents and information, just ask. You, your provider or someone you trust may ask us to delay your case until you are ready. We want to make the decision that supports your best health. This can be done by calling Member Services at 833-388-1407 (TTY 711) or writing to:

Healthy Blue
P.O. Box 62429
Virginia Beach, VA 23466

Your care while you wait for a decision
When our decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we are making a decision on your appeal. You can also ask a trusted representative to make that request for you.

You must ask us to continue your services within 10 calendar days from the date of the notice that says your care will change or by the time the action takes effect. You or your approved representative may ask to continue services when you first request an appeal by calling or writing to us at the Member Services phone number or address above.

If you ask us to continue services you already receive during your appeal, we will pay for those services if your appeal is decided in your favor. Your appeal might not change the decision we made about your services. When your appeal doesn’t change our decision, we may require you to pay for the services you received while waiting for a decision.

If you are unhappy with the result of your appeal, you can ask for a State Fair Hearing.

If you don’t agree with a decision we made that reduced, suspended or ended your services after you receive our decision about your appeal, you can ask for a State Fair Hearing from Missouri. A State Fair Hearing is your opportunity to give more information and facts, and to ask questions about your decision before an administrative law judge. The judge in your State Fair Hearing is not a part of your health plan in any way.

You have the right to ask for a State Fair Hearing if one of the following occurs:

  • Healthy Blue fails to act within required time frames for getting a service.
  • Healthy Blue fails to make an expedited decision within seventy-two (72) hours of receipt of request.
  • Healthy Blue fails to make an appeal resolution within thirty (30) calendar days of receipt of request.

If you need help with understanding the State Fair Hearing processes, you can contact MO HealthNet at 800-392-2161 or 573-751-6527 TDD users, call 800-735-2966. If you speak another language or need American Sign Language, you can ask for an interpreter at no cost to you.

If a State Fair Hearing is requested, the State will hear your case and give you a decision in writing within 90 days of the date you asked for a State Fair Hearing.

To ask for a State Fair Hearing, call MO HealthNet at 800-392-2161 or 573-751-6527 TDD users, call 800-735-2966.

You can also ask for a State Fair Hearing and your benefits to continue by sending a letter to:

MO HealthNet Division
Steakholders Services
Participant Services Unit
P.O. Box 6500
Jefferson City, MO 65102

You can also fax your letter to 855-860-9122.

The hearing is informal. You can represent yourself or a provider or other authorized representative such as a relative, a friend, or anyone else you want can help you with your okay in writing. You have one hundred twenty (120) calendar days from the Healthy Blue notice of appeal resolution to do this. If you have been getting medical care and do not want it to stop, you must ask for a State Fair Hearing within ten (10) calendar days of the date the written notice of appeal resolution was mailed and tell us not to stop the service.

Your care while you wait for a decision
When our decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we decide your case. You can also ask a trusted representative to make that request for you.

If you have been getting medical care, you must ask us to continue your services within 10 calendar days from the date of the notice that says your care will change or by the time the action takes effect. You or your approved representative may ask to continue services when you first request an appeal by calling or writing to us at the Member Services phone number or address above.

If you ask us to continue services you already receive during your State Fair Hearing case, we will pay for those services if your case is decided in your favor. Your State Fair Hearing might not change the decision we made about your services. When your State Fair Hearing case doesn’t change our decision, we may require you to pay for the services you received while waiting for a decision.

Grievances

If you are unhappy with your health plan, provider, care or your health services, you can file a grievance by phone or in writing at any time.

To file by phone, call Member Services at 833-388-1407 (TTY 711).

To file in writing, you can send your grievance to:
Healthy Blue
P.O. Box 62429
Virginia Beach, VA 23466

What happens next:
We will let you know in writing that we got your grievance within 10 calendar days of receiving it.

We will review your grievance and tell you how we resolved it in writing within 30 calendar days from receiving your grievance.

If your grievance is about the denial of an expedited appeal, we will let you know in writing that we got it within 72 hours of receiving it. We will review your grievance about the denial of an expedited appeal and tell you how we resolved it in writing within 10 calendar days of receiving your grievance.

You can ask someone you trust (such as a legal representative, a family member or friend) to file the grievance for you. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filling out the forms, we can help you. We will not make things hard for you or take any action against you for filing a grievance.

If you are not happy with how we resolved your issue, you can file an appeal with our Grievances and Appeals Department.