(928) 779-2113
Grievances and Appeals
Member Grievances
If you have a grievance or problem with a provider or a concern about the quality of care or services you have received, please call Member Services at (800) 624-4964. We will do our best to answer your questions and help you solve your problem.
Filing a grievance will not affect your health care services. We want to know your concerns so we can improve our services to you. You can call Member Services for help with problems with authorizations, covered services, payment for services or quality of services. If you call to report a grievance that is not about quality of care, we will try to solve it right away—and tell you the result right then, if we can.
If you have a quality of care grievance, we will send it to our Quality Management Department for review.
Member Appeals
An action by Capstone Health Plan means:
- The denial or limited authorization of a service which you or your doctor have requested
- The reduction, suspension or ending of an existing service
- The denial of payment for a service, either all or in part
- Failure to act within certain timeframes for grievances and appeals
Denials, Reductions, Suspension or Termination of Services and Request for Appeal
| Denial of Services | Reduction, Suspension or Termination of Services |
|---|---|
| Many services must be reviewed and approved first by Capstone Health Plan. If Capstone decides the services cannot be approved, we will write to you within 14 working days and tell you why. We will also let your doctor know. You can discuss it with your doctor. | If a reduction, suspension or ending of your services happens, we will write to you at least 10 days before the change is implemented to let you know. |
Notice of Action
If Capstone Health Plan decides that the requested service 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 that your benefits be continued during your appeal, how to do it and for information on when you may have to pay the costs for the services
Appeals Process
If you disagree with Capstone Health Plan's action about your health care services, you may file an appeal either in writing or over the phone. If you need an interpreter, one will be provided.
You, your representative or a provider acting with your written permission may file an appeal within 60 days from the date of your denial, suspension, reduction or termination letter or Notice of Action. To file an appeal, you must call or send a letter to:
Capstone Health Plan
914 N San Francisco St.
Suite A
Flagstaff, AZ 86001
928-779-2113 or 800-336-3874
Capstone Health Plan will notify the Division of Developmental Disabilities Office of Compliance and Review (DDD/OCR) within 1 working day of receipt of your appeal. Both you and Capstone Health Plan may request a 14-day extension.
DDD will review your appeal and send a decision to you in writing within 30 days. The letter will tell you what their decision was and the reason for it. If DDD upholds Capstones denial, you may then request a fair hearing with AHCCCS by following the steps listed in their decision letter to you.
If you request a hearing, you will receive information from AHCCCS about what to do. Capstone Health Plan will forward its file and documentation to the AHCCCS Office of legal Assistance.
If after the hearing AHCCCS decides that Capstone's decision was correct, you may be responsible for payment of the services you received while your appeal was being reviewed. If AHCCCS decides that Capstone Health Plan's decision was incorrect, Capstone will authorize and provide the services promptly.
Request for Expedited Resolution
You may request an expedited resolution to an appeal. You must provide supporting documentation to show that taking the time for a standard resolution could seriously jeopardize the Member's life, health or ability to attain, maintain or regain maximum function.
Upon receipt of a request for an expedited appeal, Capstone will immediately forward the information to DDD/OCR. Capstone will also provide a recommended course of action to DDD/OCR.
Capstone will work cooperatively with DDD/OCR to respond to the request for an expedited resolution to an appeal.
