What is an Appeal?

If you are dissatisfied with denial of services by B – UFC/ALTCS you may file an “appeal”. An appeal must be filed within sixty (60) days from B – UFC/ALTCS's Notice of Adverse Benefit Determination letter. The appeal can be written or verbal. If you need help with filing an appeal, call our Customer Care Center.

Who May File an Appeal?

You, as the enrollee, may file an appeal. An enrollee representative, a legal representative of a deceased enrollee's estate, or a provider acting on behalf of an enrollee, and with the enrollee's written consent, may file an appeal.

What Can You File an Appeal For?

  • Denial or limited authorization of a requested service, including the type or level of service
  • Reduction, suspension, or termination of a previously authorized service
  • Denial, in whole or in part, of payment for a service
  • Failure to provide services in a timely manner
  • Failure to act within the timeframe required for standard and expedited resolution of appeals and standard disposition of grievances
  • The denial of a rural enrollee's request to get services outside the contractor's network under 42CFR 438.52 (b)(2)(ii), when the contractor is the only contractor in the rural area.

How Do You File an Appeal?

Appeals may be requested by telephone or in writing. You may call and ask to speak to the Grievance and Appeals Team to file an appeal. You can also mail or fax the Grievance & Appeals Department. B – UFC/ALTCS will provide you with a written decision within (30) days of filing the appeal.

Additionally, the timeframes for standard and expedited appeals may be extended up to (14) days if you ask an extension or if we establish a need for an extension when the delay is in your best interest.

How Do You Request a State Fair Hearing?

If you are not satisfied with the appeal decision, you may file a request for State Fair Hearing with B – UFC/ALTCS. This request must be made in writing to B – UFC/ALTCS within 120 days of the date of receipt of the appeal decision. You can mail or fax your request. B – UFC/ALTCS will send your appeal file to AHCCCS and a hearing date will be scheduled for you to attend.

AHCCCS Administration will decide if B – UFC/ALTCS's decision was correct. If AHCCCS decides that B – UFC/ALTCS's decision was incorrect, B – UFC/ALTCS will authorize and pay for services.

Additionally, there are Legal Services Programs in your area that may be able to help you with the hearing process. General legal information about your rights can also be found on the internet at the following website:

What Is an Expedited Appeal?

You may file an expedited appeal, or it may be filed on your behalf by your provider if you need a decision more quickly than 30 days. An expedited appeal will be approved if B – UFC/ALTCS finds that the time to process a standard appeal would seriously jeopardize your health, life or ability to attain, maintain or regain maximum function. If an expedited appeal request is not approved, B – UFC/ALTCS will notify you within 24 hours and transfer the appeal to the 30-day timeframe for a standard appeal. If we agree to accept your request for an expedited appeal, B – UFC/ALTCS will make a decision not later than 72 hours following the receipt of the authorization request with a possible extension of up to 14 calendar days if the member or provider requests an extension or if B – UFC/ALTCS establishes a need for more information and the delay is in the member's interest.

Continuing Services During the Appeal Process

Yes, but the request must be in writing and must be received by B – UFC/ALTCS within 10 days of the receipt of the Notice of Adverse Benefit Determination letter. However, you may be responsible for payment of those services if B – UFC/ALTCS or a State Fair hearing decision upholds the denial.

Appeal Process for Members Who Have Been Determined to Have a Serious Mental Illness

Members who are found to have an SMI may appeal decisions about their behavioral health services, including:

  • Decisions about fees or waivers;
  • The assessment report;
  • Service plans;
  • Treatment plans;
  • Discharge plans;
  • Decisions regarding services funded through Non-Title 19/21 funds;
  • Capacity to make decisions, need for guardianship, or other protective services or needs for special assistance;
  • Decisions about the loss of eligibility for SMI services; and/ or
  • A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the member.

In addition, members also have the right to appeal the initial determination for eligibility for SMI services. SMI eligibility appeal determinations will be handled by the Crisis Response Network, Inc.

To appeal an SMI determination, please call CRN at (855) 832-2866.

SMI Appeal Timelines

B – UFC/ALTCS will send the member a written notice within five business days of when the request for an appeal was received.

B – UFC/ALTCS will have an informal conference with the member, their legal guardian, or authorized representative within seven business days of when the appeal was received.

B – UFC/ALTCS will notify the member of the time and location of the conference, in writing, at least two days prior to the date of the conference. If the member cannot come to the conference, they can request that the conference be conducted over the phone.

If the member is satisfied with the resolution of the issue at the informal conference with B – UFC/ALTCS, they will receive a written notice that summarizes the appeal, the resolution, and the date of when the resolution will be implemented.

If a resolution is not reached at the informal grievance with B – UFC/ ALTCS, and if the appeal is not related to the member's eligibility for behavioral health services, then an informal conference will be held with AHCCCS within 15 business days of when the appeal was received. The informal conference with AHCCCS is not required and the member can request to skip the second conference.

If a resolution is still not reached at the informal conference with AHCCCS, or if the member chose to skip the informal conference with AHCCCS, then the member will be provided with information on how to request an Administrative Hearing through the AHCCCS office of Behavioral Health Grievance and Appeals.

SMI Expedited Appeal Timelines

B – UFC/ALTCS will resolve expedited appeals within 72 hours after the date of receipt of the appeal request unless an extension is in effect. B – UFC/ALTCS will extend the timeframe up to extra 14 days, if more information is needed to make a decision and the extension is in the best interest of the member.

Continuing Services During the Appeal Process

Members can continue to get services they were already receiving unless a qualified provider decides that reducing or stopping services is best for the member, or if the member agrees, in writing, to reduce or terminate services. If the appeal is not decided in the member's favor they may be required to pay for the services, they received during the appeal process.