If you are dissatisfied with the decision made on your services, you may file an appeal within sixty (60) days following the receipt of a denial letter. The appeal can be written or verbal. If you need help with filing an appeal, call our Customer Care Center.
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.
You can file an appeal by calling the Banner – University Family Care (B – UFC/ACC) Customer Care Center. We will assist you in filing your appeal and we also provide interpretation services in any language at no cost to you.
You can file an appeal in writing and mail it to:
B – UFC/ACC will provide you with a written notice of appeal resolution within (30) days of filing the appeal. We may extend the timeframes up to (14) days, when you ask for an extension or if we establish a need for an extension to get additional information. When this happens, we will notify you in writing.
You may file an expedited appeal, or it may be filed on your behalf by your provider if you need an urgent decision. An expedited appeal will be approved if B – UFC/ACC 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/ACC 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/ACC will make a decision no later than 72 hours following the receipt of the appeal. We may extend the timeframe up to 14 calendar days to obtain additional information. When this happens, we will notify you in writing.
If services were reduced, suspended, or terminated, a request to continue receiving services during the appeal process must be submitted in writing to B – UFC/ ACC within 10 days of the receipt of the Notice of Adverse Benefit Determination letter. If B – UFC/ACC or a State Fair hearing decision upholds the denial, you may be responsible for payment of those services. For further information, call our Customer Care Center.
If you are not satisfied with the appeal decision, you may file a request for State Fair Hearing with B – UFC/ACC. This request must be made in writing within 90 days of the date of receipt of the appeal decision. You can mail or fax your request for a State Fair Hearing to:
Legal Services Programs are available to help you with the hearing process. Click here for general legal information about your rights.
Members who are found to have an SMI may appeal decisions about their behavioral health services, including:
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.
B – UFC/ACC will send the member a written notice within five business days of when the request for an appeal was received.
B – UFC/ACC 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/ACC 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/ACC, 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/ ACC, 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.
B – UFC/ACC will resolve expedited appeals within 72 hours after the date of receipt of the appeal request unless an extension is in effect. B – UFC/ACC 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.
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.