Grievances & Appeals

What to do if you have a problem, concern, or complaint.

There are different processes for handling problems and concerns. The process you use to handle your problem depends on two things:

  1. Whether your problem is about benefits covered by Medicare or AHCCCS (Medicaid). If you would like help deciding whether to use the Medicare process or the AHCCCS (Medicaid) process, or both, please contact our Customer Care Center.
  2. The type of problem you are having.
    • For some types of problems, you need to use the process for coverage decisions and appeals.
    • For other types of problems, you need to use the process for making complaints.

These processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

Common Terms Used

Coverage Determination (Coverage Decision): A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are also called “coverage decisions.”

Appeals: An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive.

Complaints: The formal name for “making a complaint” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also “Grievance,” in this list of definitions.

 

Please review Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints) in your Evidence of Coverage booklet.


Appeals

What is an appeal?

An appeal is any of the procedures that deal with the review of adverse coverage decisions on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, approving the health care services, or on any amounts the enrollee must pay for services.

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


Who can file an appeal?

You or someone on your behalf such as an appointed representative, or your provider.

When can an appeal be filed?

Your request must be filed within 60 calendar days from the date printed or written on the written coverage decision denial notice. If you miss the filing timeframe, and you can show good cause for missing the filing time frame for a reconsideration, University Care Advantage will consider the circumstances that prevented the timely filing of your request. The party requesting the extension must file a written request and include the reason for the delay.

Where can an appeal be filed?

An appeal (Part C Reconsiderations or Part D Redeterminations) can be made over the phone, or through mail, fax or e-mail. 

  • Phone: (877) 874-3930 / TTY 711
  • Mail: Banner – University Care Advantage
    Attn: Grievance & Appeals Department
    2701 E. Elvira Road
    Tucson, AZ 85756
  • Fax: (866) 465-8340
  • Email: BUHPGrievances&Appeals@bannerhealth.com

Additional Information

You have the right to get a summary of information about the appeals, grievances, and exceptions that members have filed against Banner – University Advantage in the past. Call our Customer Care Center to request this information.

To obtain total number of grievances, appeals and exceptions filed with Banner – University Care Advantage, contact: (877) 874-3930 and ask for the Grievance and Appeals Department.

You can also file a complaint or get information directly from Medicare. You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, TTY/TDD users should call 1-877-486-2048. You can also visit the Medicare website at http://www.medicare.gov.

Related Forms

  • Medicare Complaint Form     
English        Español     
  • Appointment of Representative Form     
English        Español     

Grievances

What is a grievance?

A grievance is another term used for making a complaint about quality of care, waiting times, customer service, or other concerns.

Who can file a grievance?

You or someone on your behalf such as an appointed representative.

When can a grievance be filed?

Your grievance or complaint must be filed within 60 calendar days after you experience the problem.

Where can a grievance be filed?

Send your appeal via mail, fax or e-mail.

  • Phone: (877) 874-3930 / TTY 711
  • Mail: Banner – University Care Advantage
    Attn: Grievance & Appeals Department
    2701 E. Elvira Road
    Tucson, AZ 85756
  • Fax: (866) 465-8340
  • Email: BUHPGrievances&Appeals@bannerhealth.com

Grievance by phone

If you call us and we cannot resolve your complaint over the phone, we will respond to you within 30 calendar days from the date you file the complaint. The longest time Banner – University Care Advantage can take to answer a complaint is 30 days. If Banner – University Care Advantage needs more information or the delay will benefit you, we can take up to 14 days more to respond to your complaint. We will notify you of the need for the 14-day extension, the reason for the extension and how it is in your best interest, and instructions on how to file a “fast” or expedited complaint if you do not agree with our decision to take the extension.

Grievance in writing

If you file a written grievance, have a complaint related to quality of care, or ask for a written response, then Banner – University Care Advantage will respond to you in writing. You have two options for filing a quality of care complaint. You may file your quality of care complaint with Banner – University Care Advantage and/or directly with the Quality Improvement Organization (QIO).

QIO Contact Information

In Arizona, the QIO is Livanta, LLC:

  • Phone: (877) 588-1123; TTY: (855) 887-6668
  • Mail: Livanta BFCC-QIO Program
    10820 Guilford Road, Suite 202
    Annapolis Junction, MD 20701
  • Fax: Appeals - (855) 694-2929, All other reviews - (844) 420-6672
  • Website: www.livantaqio.com

Additional Information

You have the right to get a summary of information about the appeals, grievances, and exceptions that members have filed against Banner – University Care Advantage in the past. Call our Customer Care Center to request this information.

To obtain total number of grievances, appeals and exceptions filed with Banner – University Care Advantage, contact: (877) 874-3930/TTY 711, and ask for the Grievance and Appeals Department.

You can also file a complaint or get information directly from Medicare. You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, TTY/TDD users should call 1-877-486-2048. You can also visit the Medicare website at www.medicare.gov.

Related Forms

Medicare Complaint Form English Español

Appointment of Representative Form English Español


Member Rights & Responsibilities

Your Rights

Our plan must honor your rights as a member of the plan.

  • We must provide information in a way that works for you (in languages other than English, in braille, in large print, or other alternate formats, etc.).
  • We must treat you with fairness and respect at all times.
  • We must ensure that you get timely access to your covered services and drugs.
  • We must protect the privacy of your personal health information.
  • We must give you information about the plan, its network of providers, and your covered services.
  • We must support your right to make decisions about your care.
  • You have the right to make complaints and to ask us to reconsider decisions we have made.

Your Responsibilities

  • Get familiar with your covered services and the rules you must follow to get these covered services.
  • If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us.
  • Tell your doctor and other health care providers that you are enrolled in our plan.
  • Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
  • Tell us if you move.

For more information, please review Chapter 8, "Your Rights and Responsibilities" in your Evidence of Coverage booklet.


Appointment of Representative

You can appoint an individual to act as your representative. With your authorization, the appointed individual can do the following on your behalf:

  • Make any request
  • Present or gather evidence
  • Obtain appeals information
  • Receive any notice in connection with an appeal

To request an Appointment of Representative Form, please call our our Customer Care Center or print out the form listed below.

The form must be signed by you and by the person who you would like to act on your behalf. You must also give us a copy of the signed form. See our Contact Us page if you need to ask us a question or would like to send your form to us. 

Related Forms

Appointment of Representative Form English Español