Grievance and Appeals
If you are unhappy with your services or do not agree with a decision made about your services, make your voice heard by contacting the Care1st Health Plan Arizona Grievance and Appeal Department. Care1st Health Plan Arizona staff are trained to respond to member concerns in a courteous, responsive, and timely manner. You may file a grievance or an appeal whether or not you are TXIX/XXI (AHCCCS) eligible. For individuals who are Non-TXIX/XXI, you may file a grievance or an appeal related to the services that are covered by Care1st Health Plan Arizona.
Please see below for more information about Grievances and Appeals. If you are a member determined to have a serious mental illness (SMI), please also review SMI Grievances/Investigations and SMI Appeals. You will also find more details about your grievance and appeal rights in your member handbook.
Have questions?
If you have questions or need help with the process for filing a grievance or an appeal please contact Care1st Health Plan Arizona Member Service at 1-866-560-4042 TTY/TDD: 711 and ask to speak to the Grievance and Appeal Department. You may also write to us at:
Care1st Health Plan Arizona
Attention: Grievance and Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
If you decide to file an SMI grievance or appeal please use the following form to request a review of a decision by Care1st Health Plan Arizona. Please see below for more details and requirements for the appeals process.
Filing an Appeal
Appeals can be filed verbally or in writing within 60 days after the date of a Notice of Adverse Benefit Determination or Notice of Decision and Right to Appeal. The Notice explains to you how to file an appeal and what the deadline is for filing an appeal. However, if you have any questions the Care1st Health Plan Arizona Grievance and Appeal Department is available to help you. To reach a Grievance and Appeal Department representative, please contact Care1st Health Plan Arizona Member Service.
You or your legal representative can file an appeal. An authorized representative, including a provider, can also file an appeal for you with your written permission. You can also get help with filing an appeal by yourself.
In some cases, Care1st Health Plan Arizona will review an appeal on an expedited basis. An expedited appeal is resolved within 72 hours due to the urgent health needs of the person filing the appeal. Contact Care1st Health Plan Arizona Member Service or your provider to see if your appeal will be expedited. If your appeal is not expedited it will be resolved within 30 calendar days of the date it is received.
Need Help?
To file an appeal verbally or for help with filing a written appeal, call 866-560-4042 or TTY/TDD: 711. To file an appeal by mail, send your appeal and documentation to:
Care1st Health Plan Arizona
Attn: Grievance and Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
You will get written notice that your appeal was received within 5 business days. If your appeal is expedited, you will get notice that your appeal was received within 1 business day. If Care1st Health Plan Arizona has decided that your appeal does not need to be expedited, your appeal will follow the standard appeal timelines. Care1st Health Plan Arizona will make a reasonable effort to call you with the decision not to expedite your appeal and follow up within 2 calendar days with a written notice.
You have the right to ask for a review of the following Adverse Benefit Determinations:
- The denial or limited approval of a service asked for by your provider or clinical team;
- The reduction, suspension, or termination of a service that you were receiving;
- The denial, in whole or part, of payment for a service;
- The failure to provide services in a timely manner;
- The failure to act within timeframes for resolving an appeal or complaint; and
- The denial of a request for services outside of the provider network when services are not available within the provider network.
As part of the appeal process, you have the right to give evidence that supports your appeal. You can provide the evidence to Care1st Health Plan Arizona in person or in writing. In order to prepare for your appeal, you may examine your case file, medical records, and other documents and records that may be used before and during the appeal process, as long as the documents are not protected from disclosure by law. If you would like to review these documents, contact your provider or Care1st Health Plan Arizona. The evidence you give to Care1st Health Plan Arizona will be used when deciding the resolution of the appeal.
Care1st Health Plan Arizona will give you a decision, called a Notice of Appeal Resolution, in person or by certified mail within 30 days of getting your appeal for standard appeals, or within 72 hours for expedited appeals. The Notice of Appeal Resolution is a written letter that tells you the results of your appeal.
The resolution date may be extended by up to 14 days. You or Care1st Health Plan Arizona can ask for more time in order to gather more information. If Care1st Health Plan Arizona asks for more time, you will be given written notice of the reason for the extension.
When we have completed our review, you will receive a Notice of Appeal Resolution that will tell you:
- The outcome of the appeal; and
- The reason(s) for the decision
If your appeal was denied, in whole or in part, then the Notice of Appeal Resolution will also tell you:
- How you can ask for a State Fair Hearing;
- How to ask that services continue during the State Fair Hearing process, if applicable;
- The reason why your appeal was denied and the legal basis for the decision to deny your appeal; and
- That you may have to pay for the services you get during the State Fair Hearing process if your appeal is denied at the State Fair Hearing.
You can ask for a State Fair Hearing if you are not happy with the results of an appeal. If your appeal was expedited, you can ask for an expedited State Fair Hearing. YOU HAVE THE RIGHT TO HAVE A REPRESENTATIVE OF YOUR CHOICE ASSIST YOU AT THE STATE FAIR HEARING.
You must ask for a State Fair Hearing in writing within 120 days of getting the Notice of Appeal Resolution. This includes both standard and expedited requests for a State Fair Hearing. Requests for State Fair Hearings should be mailed to:
Care1st Health Plan Arizona
Attn: Grievance and Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
Filing a Grievance
If you are not happy with your care you may file a grievance. A grievance is a complaint. You may file a grievance against a service provider or against Care1st Health Plan Arizona. Examples of grievances include delays in services and dissatisfaction with the quality of care or quality of service you received.
You may also file a grievance if you received a Notice of Adverse Benefit Determination that you do not understand or is not correct. If Care1st Health Plan Arizona does not resolve your concern about the Notice, you may also contact the AHCCCS Clinical Resolution Unit.
Once filed, your grievance will be reviewed and a response will be provided no later than 90 days from the date that you contacted us. In most cases we will complete our review and provide a response within 10 calendar days.
If you are a member determined to have a serious mental illness (SMI), you have the right to file an SMI grievance if you believe your rights were violated by a mental health provider. You may also request an investigation related to a condition requiring investigation (an incident or condition that appears to be dangerous, illegal, or inhumane). Your legal rights include (but are not limited to):
Need Help?
You may also file a grievance by calling the Member Service Department between 8:00 a.m. and 5:00 p.m. at 1-888-788-4408 or TTY/TDD: 711.
You may also file a grievance in person or in writing. You may file your grievance in writing by mailing it to:
Care1st Health Plan Arizona
Attn: Grievance and Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
- The right to be free from unlawful discrimination;
- The right to equal access to behavioral health services;
- The right to privacy;
- The right to be informed; and
- The right to be assisted by an attorney or representative of your choosing.
See Arizona Administrative Code Title 9, Chapter 21 (PDF), Article 2, for a more complete list of your civil and other legal rights.
If you feel your rights have been violated or a condition requiring investigation exists, please contact Care1st Health Plan Arizona Member Service Department between 8:00 a.m. and 5:00 p.m. at 1-888-788-4408 or TTY/TDD: 711.
We will help you with the process for initiating a grievance or requesting an investigation. You may also request to speak to someone in person:
In person
Care1st Health Plan Arizona
Grievance and Appeal Department
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281
SMI Appeals
In addition to the right to appeal denials of AHCCCS covered services, persons determined to have an SMI may appeal the following:
- A decision regarding fees or waivers;
- The denial, reduction, suspension or termination of any covered service;
- Capacity to make decisions, need for guardianship or other protective services or need for special assistance;
- A decision is made that the person is no longer eligible for SMI services; and
- A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the person.
If you file an appeal, you will get written notice that your appeal was received within 5 business days of Care1st Health Plan Arizona’s receipt. For an appeal that needs to be expedited, you will get written notice that your appeal was received within 1 business day of Care1st Health Plan Arizona’s receipt, and the informal conference must occur within 2 business days of filing the appeal.
You will have an informal conference with Care1st Health Plan Arizona within 7 working days of filing the appeal. The informal conference must happen at a time and place that is convenient for you. You have the right to have a designated representative of your choice help you at the conference. You and any other participants will be informed of the time and location of the conference in writing at least two days before the conference. If you are unable to come to the conference in person, you can participate in the conference over the telephone.
If there is no resolution of the appeal during this informal conference, and if the appeal does not relate to your eligibility for behavioral health services, the next step is a second informal conference with AHCCCS. This second informal conference must take place within 15 days of filing the appeal. If the appeal needs to be expedited, the second informal conference must take place within 2 working days of filing the appeal. You have the right to skip this second informal conference.
If there is no resolution of the appeal during the second informal conference, or if you asked that the second informal conference be skipped, you will be given information that will tell you how to request an Administrative Hearing.
If you file an appeal you will continue to get any services you were already getting unless a qualified clinician decides that reducing or terminating services is best for you, or you agree in writing to reducing or terminating services. If the appeal is not decided in your favor, Care1st Health Plan Arizona may require you to pay for the services you received during the appeal process.
Persons asking for a determination of Serious Mental Illness (SMI) and persons who have been determined to have a SMI can appeal the result of a SMI determination.
If you request an SMI Determination, the decision will be made by Solari, Inc. Solari, Inc.is a statewide provider that that performs Serious Mental Illness (SMI) determinations.
If you or your provider requests an SMI determination, Solari, Inc. will send you a letter by mail to let you know what the final decision on your SMI determination is. This letter is called a Notice of Decision. If Solari, Inc. finds that you are not eligible for SMI services, the letter will tell you why. If you do not get the letter/notice by the end of the time you agreed to (three (3), 20 or 90 days), please call Solari, Inc. at 1-800-203-2273. Solari, Inc. will send you a letter by mail to let you know the final decision on your SMI determination. This letter is called a Notice of Decision. If Solari, Inc. finds that you are not eligible for SMI services, the letter will tell you why. If you do not get the letter/notice by the end of the time you agreed to, please call Solari, Inc. at 1-800-203-2273
You have a right to appeal your SMI determination.
To appeal, you must contact Solari, Inc. at 1-800-203-2273. Solari, Inc. will provide you a letter that will include information on your member rights and how to appeal the SMI determination.
For more information, please contact:
Solari, Inc.
1275 West Washington Street
Suite 210
Tempe, AZ 85281
1-800-203-CARE (2273)