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Grievances and appeals

As an Amerigroup STAR+PLUS MMP member, you have the right to make complaints and to ask us to reconsider decisions we have made. These are called grievances and appeals.

What is a grievance?

A grievance is a complaint about us or one of our providers that doesn’t involve a decision about care or services you requested.

How can I file a grievance?

You can file a grievance in one of these ways:

  1. Call Member Services at 1-855-878-1784 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free.
  2. Mail a letter to:
    Amerigroup STAR+PLUS MMP
    Complaints, Appeals, and Grievances
    Mailstop: OH0205-A537
    4361 Irwin Simpson Road
    Mason, OH 45040
  3. Fax: 1-888-458-1406

Be sure to include as many details as you can about your complaint.

What is an appeal?

If we make a coverage decision — a decision about care or services you requested — and you’re not satisfied with our decision, you can file an appeal. An appeal is a formal way of asking us to review and change a coverage decision we made.

How do I file an appeal?

You can file an appeal in one of these ways:

  1. Call Member Services at 1-855-878-1784 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free.
  2. Mail a letter to:
    Amerigroup STAR+PLUS MMP
    Complaints, Appeals, and Grievances
    Mailstop OH0205-A537
    4361 Irwin Simpson Road
    Mason, OH 45040
  3. Fax: 1-888-458-1406

For Part D Drug appeals, complete the  Request for Redetermination of Medicare Prescription Drug Denial form or call 1-833-232-1711 (TTY:711) 24 hours a day, 7 days a week.

You must file an appeal within 60 calendar days from the date on the letter we sent to tell you our decision.

The decision timeframe depends on the type of appeal you file.

  • Standard Part D drug: 7 calendar days (benefits) or 14 calendar days (payments)
  • Standard service appeal (including Non-Part D drugs): 30 calendar days or within 7 calendar days after we get your appeal for a Medicare Part B prescription drug
  • Payment appeal: 60 calendar days

If your health requires it, you can ask for a fast (expedited) decision on your appeal. If you ask for a fast appeal, we will give you your answer within 72 hours after we get your expedited appeal request.

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 form if you choose to have someone else submit the appeal on your behalf
If we decide to change or stop coverage for a Texas Medicaid-covered service that was previously approved, we will send you a notice before taking the action.

If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits. You must make the request on or before the later of the following in order to continue your benefits: 
  • Within 10 calendar days after the date of our notice of action; or
  • The intended effective date of the action

Part D drug appeals

When you receive our appeal decision, you can ask for an Independent Review. At this stage of the process, you should contact the Independent Review Entity (IRE) directly.

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Avenue Suite 703
Pittsford, NY 14534-1302
Phone: 1-585-348-3300
Fax: 1-720-462-7575

Part C appeals (including non-Part D drugs)

If we don’t decide in your favor, your case is sent to the Independent Review Entity (IRE). We’ll send you a letter to tell you if this happens.

Note: If your problem is about a service or item that could be covered by both Medicare and Texas Medicaid, you will automatically get a Level 2 Appeal with the IRE. You can also ask for a Level 2 Appeal (known as a Fair Hearing) with the HHSC Appeals Division. If the IRE and the state make different decisions, we’ll follow the decision that is most favorable to you.
 

If your appeal involves items or services covered by Texas Medicaid or by Medicare and Texas Medicaid, you can ask for a Fair Hearing after you receive your appeal decision letter telling you we decided to uphold our initial decision. Contact Amerigroup STAR+PLUS MMP in writing. We will send your Fair Hearing request to the HHSC Appeals Division. You or your representative must ask for a Fair Hearing within 120 days of the date on the appeal decision letter telling you we were not able to change our decision. Mail your request to:

Fair Hearing Coordinator
Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan)
5959 Corporate Drive, Suite 1300
Houston, TX 77036

Or you can call Member Services at 1-855-878-1784 (TTY: 711), Monday through Friday from 8 a.m. to 8 p.m. local time. This call is free. We can help you with this request. If you need a fast decision because of your health, you should call Member Services to ask for an expedited Fair Hearing.

After your hearing request is received by the HHSC Appeals Division, you will get a packet of information letting you know the date, time, and location of the hearing. Most Fair Hearings are held by telephone. During the hearing, you or your representative can tell the hearing officer why you need the service that we denied.

The HHSC Appeals Division will give you a final decision within 90 days from the date you asked for the hearing. If you qualify for an expedited Fair Hearing, the HHSC Appeals Division must give you an answer within 72 hours.

We may be able to continue your benefits through the State Fair Hearing process if you continued to get services through the internal appeals process and you ask for continuation of benefits and a State Fair Hearing within 10 calendar days after the date of our notice that we upheld our initial decision to your appeal.

Appointed representative

You can ask someone to represent you when you submit a grievance or ask for an appeal. An appointed representative can be:

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

Fill out the Appointment of Representative form and mail it to us to have someone act on your behalf.

More information

For more information on how to submit a complaint about your health plan or Medicaid services and what to expect after you submit a complaint, review How to Submit A Complaint in  English or Spanish .

To find out how many appeals, grievances, and exceptions have been filed with our plan over the past year or to get the status of your request, call Member Services at 1-855-878-1784 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. local time. This call is free.

If you feel you have used all your options with us, you may file a complaint directly with Medicare

Updated 08/03/2020
H8786_20_117495_R CMS Approved 02/10/2020