v3-txMMP.css

Grievances & Appeals

What is a grievance?

You have a right to file a grievance. A grievance is a complaint that doesn’t involve our decision to pay for a drug or service covered by Amerigroup STAR+PLUS MMP. You can ask someone to represent you when you ask for a grievance or an appeal. An appointed representative can be:

  • A relative
  • A friend
  • An advocate
  • A doctor

Fill out the Appointment of Representative form to have someone act on your behalf.

How do I file a grievance?

You can call Member Services over the phone at 1-855-878-1784 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. local time. A Member Services representative will record your grievance.

You can send a grievance in writing to us at:

Amerigroup STAR+PLUS MMP
MMP Appeals and Grievances
Mailstop OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040

Or by Fax: 1-888-458-1406

What is an appeal?

If we make a coverage decision and you are not satisfied with the decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we made.

How do I file an appeal?

The way you file an appeal depends on the service.

You must file an appeal within 60 days of the coverage decision. Call Member Services or submit appeals in writing to:

Amerigroup STAR+PLUS MMP
MMP Appeals and Grievances
Mailstop OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040

Fax: 1-888-458-1406

For Part D Drugs appeals, you can also email:
SeniorG&AIntake@anthem.com

You'll receive a decision within:

  • Part D drug: 7 calendar days
  • Non-Part D drug: 30 calendar days
  • Standard service appeal: 30 calendar days
  • Payment appeal: 60 calendar days
What if I need a fast (expedited) decision on my appeal?

You must file an appeal within 60 days of the coverage decision. Call Member Services or submit appeals in writing to:

MMP Appeals and Grievances
Mailstop OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040

Phone: 1-855-878-1784 (TTY: 711)

Fax: 1-888-458-1406

For Part D Drugs, email:
SeniorG&AIntake@anthem.com

You'll receive a decision within:

  • Part D Drug: 72 hours
  • Non-Part D Drug: 30 calendar days
  • Standard Service Appeal: 72 hours
What should I include with my appeal?

If your appeal is about a Part D drug

The appeal form included in the denial letter. You can also get a copy by calling Member Services or visiting our website.

  • Any information (documents, medical records) to support your appeal
  • An Appointment of Representative (AOR) form if a person other than you or your prescribing physician is appealing on your behalf

If your appeal is about a Non-Part D drug, Medicare-covered service or Medicaid-covered service

  • You don’t need a special appeal form. Just submit your reason in writing with:
  • Any information (documents, medical records) to support your appeal
  • An Appointment of Representative (AOR) form if you choose to have someone else submit the appeal on your behalf
Can I still get services while my appeal is being processed?

Part D drug: Not applicable

Non-Part D drug, Medicare-covered service or Medicaid-covered service: You or your PCP must request continuation of previously approved services during the appeal process

What can I do if the appeal decision is unfavorable?

If your appeal was about a Part D drug:

If we don’t decide in your favor, we’ll send you a letter to tell you. You will have to reach out directly to the IRE at this stage of the process.

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Avenue, Suite 703
Pittsford, New York 14534-1302
Phone: 1-585-348-3300
Fax number: 585-425-5301
Customer Service: 585-348-3400

If your appeal was about a Non-Part D drug or a Standard Service Appeal:

If we don’t decide in your favor, your case is auto-forwarded to the independent review entity (IRE). We’ll send you a letter to tell you if this happens. You will have to reach out directly to the IRE at this stage of the process.

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 702
Pittsford, New York 14534-1302
Phone: 1-585-348-3300
Fax number: 585-425-5301
Customer Service: 585-348-3400

Note: If there is an adverse determination for a service covered by both Medicare and Medicaid, it will be auto-forwarded to the IRE, and you may also ask the HHSC Appeals Department. If both the IRE and the state make decisions, we’ll follow the decision that is most favorable to you.

The Texas Department of Aging and Disability Services (DADS)
P.O. Box 149030
Austin, Texas 78714-9030
Phone: 512-438-3011

Office of Administrative Hearings
P.O. Box 13025
Austin, Texas 78711-3025
Phone: 512-475-4993

To find out how many appeals, grievances and exceptions have been filed with our plan or to get the status of your request, call Member Services.

Updated – 2/21/2018
H8786_18_33996_R CMS Approved 2/14/2018