MCO Appeals and Grievances

An appeal is when you ask for a formal hearing when you do not agree with a decision made by your health plan. You have the right to appeal when your health plan:

  • Denies or limits a service approval request
  • Does not approve a service in an amount length of time, or scope that you requested
  • Denies payment for a service
  • Suspends, reduces, discontinues, or terminates services
  • Doesn't act upon your grievance or appeal within required timeframes
  • Denies your request to disagree with a bill

Requesting an appeal with your health plan:

  • Contact a member representative from your health plan by phone or mail
  • The member handbook from your health plan tells you how to file an appeal
  • You have sixty (60) days from the date on your notice of adverse benefit determination to request an appeal with your health plan

More Information is available in the member handbooks for your plan at the following links:

Requesting a State Fair Hearing:

You can request a State Fair Hearing after your appeal to the health plan has been finalized