Grievance / Appeals
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problem or complaint
You have the right to make a complaint if you have concerns or problems related to your coverage or care. Grievances and appeals are two different types of complaints you can make. Which one you make depends on your situation. This section outlines the grievance and appeals process for Abrazo Advantage Health Plan (HMO).
For more information about Grievances & Appeals please click on the link for your plan's Evidence of Coverage - Chapter 9.
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What is a Grievance?
A grievance is an expression of dissatisfaction with Abrazo Advantage Health Plan, one of our plan providers, or one of our network pharmacies. You can file a grievance, orally or in writing, within 60 calendar days after you had the problem you want to complain about.
Examples of grievances:
- You are unhappy with the way a person at AAHP has treated you.
- You don't think you're receiving quality health care.
- You can't see your doctor in a timely fashion.
- You are unable to reach someone by phone or get the information you need.
AAHP will acknowledge receipt of a standard grievance by mail or by phone within 5 calendar days of the receipt of the grievance. We must notify you of our decision about your standard grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. In some cases, we may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
Expedited Grievance
You may also request an expedited grievance when your request for an expedited medical or drug determination or expedited appeal was denied or we extend the time frame to make a medical or drug determination or appeal. We must notify you of our decision on an expedited grievance within 24 hours. If a denial or delay may put your life or health at risk it is considered an expedited grievance.
If your complaint involves a quality of care issue, you also have the right to file a grievance directly with the Quality Improvement Organization. This independent review organization contracts with the federal government and is not part of our plan. More information on the Quality Improvement Organization can be found in your Evidence of Coverage, Chapter 2,
Section 4.
How to File a Grievance:
Any member, or their designated representative, may file a grievance by calling or writing using the contact information below.
For information on appointing a representative click here.
You can file:
Online: Click here
By Phone:
(602) 824-3900 or (888) 864-1114
By Mail:
Abrazo Advantage Health Plan (HMO)
Grievance & Appeals Department
7878 N. 16th Street, Ste., 105
Phoenix, AZ 85020
By Fax: (602) 674-6673
For grievance process or status questions contact us:
By Phone: (602) 824-3900 or (888) 864-1114
What is an Appeal?
You have the right to file an expedited or standard appeal, either orally or in writing. An appeal is the type of complaint you make when you want us to reconsider or change a decision we made about what benefits are covered for you or what you paid for a benefit.
Examples of appeals:
- Your request for a health care service, supply or prescription is denied.
- You disagree about the amount you must pay for a health care service.
- AAHP denies your request to change the amount you must pay for a prescription drug.
Once AAHP receives your appeal we will acknowledge our receipt of your appeal in writing within 5 calendar days for Standard Medical Appeals and within 24 hours for Expedited Medical Appeals.
Standard Medical Appeal
AAHP will give you a decision no later than 30 days after we receive your appeal. If you request an extension or AAHP needs additional information we may extend this time by up to 14 calendar days.
Expedited Medical Appeal
AAHP will make a decision on an expedited appeal no more than 72 hours after receipt of your request. If you request an extension or AAHP needs additional information we may extend this time by up to 14 calendar days.
First Step for Standard Payment Appeal
Once AAHP receives your appeal we will acknowledge our receipt of your appeal in writing within 5 calendar days. The expedited appeal process doesn't apply to standard payment appeals.
Standard Payment Appeal
AAHP will process payment for the service within 60 calendar days of our receipt of the request. If we deny payment, in whole or in part, we will send the complete case file to an independent review entity contracted by Medicare no later than 60 calendar days from the date the request is received.
First Step in the Prescription Drug (Redetermination) Appeal Process
Once AAHP receives your Standard or Expedited Prescription Drug Appeal we will acknowledge our receipt of your appeal in writing within 24 hours.
A prescribing physician or other prescriber may act on your behalf in requesting a standard or expedited prescription drug (redetermination) appeal without being an appointed representative.
Use this form to submit your redetermination request.
Standard Prescription Drug (Redetermination) Appeal
You may appeal a decision related to pharmacy by submitting a signed written request. An AAHP representative will render a decision within 7 calendar days.
Expedited Prescription Drug (Redetermination) Appeal
You may submit an expedited appeal either orally or in writing. An AAHP representative will contact you within 24 hours of the date and time of receipt of the expedited pharmacy appeal.
If your Appeal is denied by Abrazo Advantage Health Plan
For Medicare Advantage (Part C) Medical Appeals:
If we deny any part of your appeal, your case will automatically be forwarded to an independent review organization to review your case.
This independent review organization contracts with the federal government and is not part of our plan. The independent reviewer will review our decision. If any of the medical care or service you requested is still denied, you can appeal to an administrative law judge if the dollar value of your appeal meets the minimum federal requirement. You will be notified of your appeal rights if this happens.
For Part D Prescription Drug Appeals:
If we deny any part of your appeal, you must request in writing for your case to be independently reviewed by an independent review organization. This independent review organization contracts with the federal government. The independent review organization will review our decision. If any prescription drug is still denied, you can appeal to an administrative law judge if the dollar value of your appeal meets the minimum federal requirement. You will be notified of your appeal rights if this happens.
How to file an Appeal either orally or in writing.
Any member, or their designated representative, may file an appeal by calling or writing using the contact information below.
For information on appointing a representative click here.
Contact Information:
By Phone: (602) 824-3735 or (888) 864-1114
(Ask for the Appeals Department)
By Mail:
Abrazo Advantage Health Plan (HMO)
Grievance & Appeals Department
7878 N. 16th Street, Ste., 105
Phoenix, AZ 85020
By Fax: (602) 674-6673
For appeal process or status questions contact us:
By Phone: (602) 824-3900 or (888) 864-1114
(Ask for the Appeals Dept.)
Need Assistance?
AAHP Member Services
(602) 824-3900 or (888) 864-1114
Seven days a week, 8 am to 8 pm
Hearing Impaired Assistance
TTY/TDD (800) 842-4681 to access the Arizona Relay System
Filing a Complaint (Appeal or Grievance) with Medicare
The Office of the Medicare Ombudsman helps you with complaints, grievances, and information requests. Click here to learn how the Office of Medicare Ombudsman can assist you.
You will be redirected to the Medicare.gov site