Fillable Printable Appeal Brochure

Appeal Brochure

 It is best to file an appeal in writing on the

appeal/grievance form (available from the

provider, RBHA, contractor or on the OHR

website).

 If an appeal is submitted after the appeal

deadline has passed it can be acceptedfor good

cause; however, the RBHA or contractor has

the right to refuse to accept a late appeal (R9-

21-401(D)).

 If the RBHA or contractor refuses the appeal,

the individual may, within 10 days of receipt of

the RBHA’s refusal, request an Administrative

Review of the decision with the AHCCCS/

DHCAA Office of Grievance and Appeals.

 Remember:The RBHA, contractor and/or

provider cannot retaliate (punish) an individ-

ual who decides to exercise the right to appeal.

1st Step: Informal Conference with the

RBHA or Contractor (R9-21-401(E))

 After receiving and accepting an appeal, the

RBHA or contractorshall set up and hold an

informal conference with the individual and

provider to attempt to resolve the issues in dis-

pute.

 If the issues in dispute are not resolved through

the conference and the issues in dispute do not

relate to the individual’s eligibility for SMI

services, the matter will be forwarded to

AHCCCS/DHCAA for a second informal con-

ference.

 An individual has the option to waive the

AHCCCS/DHCAA informal conference, which

results in the appeal going toan administrative

hearing at the Office of Administrative Hearing

(OAH).

 If the issue on appeal is eligibility for SMI

services, there is no second informal conference.

Instead, the individual can request an

administrative hearing.

Appeal Process for Individuals

Determined to Have a Serious

Mental Illness

The SMI appeal process is available to individu-

als determined to have a Serious Mental Illness

(SMI) and to individuals disputing a SMI eligi-

bility determination. This brochure covers who

can file an appeal, what issues can be appealed

and the steps involved in the process. The rules

of the appeal process are in the Arizona Admin-

istrative Code, Title 9, Chapter 21, Section 401,

available at www.azsos.gov/public_services/

Title_09/9-21.htm. Also, sections GA 3.3 & 3.5

of the AHCCCS/DHCAA Policy & Procedures

at //www.azahcccs.gov/shared/Downloads/

MedicalPolicyManual/320R.pdf may be helpful.

Who Can File an Appeal?

The individual applying for or receiving services

or the individual’s guardian, designated

representative, or service provider can file an

appeal (R9-21-401(D)).

What Can be Appealed?

 SMI eligibility determination

 Content of individual service plan or

discharge plan

 Denial of a service

 Reduction, suspension or termination of a

service

 Fees assessed to the individual or the denial

of a fee waiver

 Denial of payment for a service

 Others, per R9-21-401(C)

How are Appeals Filed?

Appeals are filed by notifying the Regional

Behavioral Health Authority (RBHA)* Office of

Grievance and Appeals or Contractor—orally or

in writing—of the decision, report, plan or ac-

tion being appealed with a brief statement of

the reasons for the appeal, generally within 60

days** of the decision or event. (R9-21-401

(D)).

*If acurrent service is being changed or terminated, file the appeal

by the shorter deadline (usually 10 days or by the date of the action)

to ensure continuation of services during the appeal.

2nd Step: Informal Conference with

ADHS/DBHS (R9-21-401(F))

 AHCCCS/DHCAA shall holdan informal confer-

ence upon notice that the appeal was unresolved

in the RBHA informal conference (unless the in-

dividual waives an informal conference with

AHCCCS/DHCAA, or the issue on appeal is eligi-

bility for SMI services).

 If the issues in dispute are not resolved through

the AHCCCS/DHCAA informal conference, the

individual may request an administrative hearing.

3rd Step: Administrative Hearing

(R9-21-401(G))

 At the administrative hearing, the individual and

the opposing partyhave the right to present any

evidence relevant to the issues under appeal and to

call and question witnesses.

 At the conclusion of the hearing, the hearing

officer shall prepare and distribute a written,

proposed decision based on the evidence

introduced at the hearing to AHCCCS/DHCAA.

 AHCCCS/DHCAA shall then make a final written

decision, based upon the findings, conclusions,

and recommendations of the hearing officer.

Additional Actions Available After the

Administrative Hearing

 If the individual does notagree with the

AHCCCS/DHCAA decision that was issued after

the administrative hearing, the individual can:

 file for a rehearing or review of the decision

(R9-21-401(J)); or

 appeal the decision to the Superior Court,

which may affirm, reverse, modify, or vacate

and remand the decision (A.R.S. §12-910).

 If the individual requests a rehearing or a review

of the decision and is not satisfied with the

decision on reviewor rehearing, the individual

can appeal that decision to the Superior Court.

What are the Steps of the

Appeal Process?

OHR/7-22-2009; revised 10/27/17

Division of Health Care

Advocacy and

Advancement

Overview of the Appeal

Process for Individuals

Determined to Have a

Serious Mental Illness

The Office of Human Rights publishes other

self-advocacy documents on various topics.

You can download them from our website or

call our office to request a copy.

The intent of this brochure is to provide

general information to individuals deter-

mined to have a Serious Mental Illness in

Arizona’s public behavioral health system

regarding their rights. It is not intended as a

substitute for individual guidance or advice.

Additionally, the AHCCCS/DHCAA Office

of Human Rights is not a law firm.

Do Services Continue During the Ap-

peal Process for Individuals Determined

to Have a Serious Mental Illness?

An individual’s services continue during the

appeal process when an appeal is timely filed,

unless (R9-21-401(A)):

 A qualified clinician determines that the

modification or termination is necessary to

avoid a serious or immediate threat to the

health or safety of the individual; or

 The individual or individual’s guardian

agrees in writing to the modification or

termination.

Can an Appeal be Expedited?

An appeal can be expedited upon request if:

 It involves the denial or termination of

crisis or emergency services;

 It involves the denial of admission to or

the termination of inpatient services; or

 The individual can show good cause to

support the need for an expedited appeal

(R9-21-401(H)).

Are There any Special Provisions for

Title XIX Services?

Instead of the standard SMI appeal process,

individuals who have Title XIX status

(AHCCCS coverage) can use the TXIX appeal

process for decisions relating to TXIX services

(R9-21-401(I)).

Are There any Special Provisions for

Tribal RBHAs

While appeals are normally filed with the

RBHA and contractors, appeals related to a

Tribal RBHA must be filed with and

processed by the AHCCCS/OALS Grievance

and Appeals.

How to Contact Us

Flagstaff Office

877-744-2250 (toll free)

928-214-8231

2717 North Fourth Street

Suite 130

Flagstaff, Arizona 86004

Phoenix Office

800-421-2124 (toll free)

602-364-4585

701 East Jefferson Street

Phoenix, AZ 85034 MD9005

Tucson Office

877-524-6882 (toll free)

520-770-3100

400 W. Congress, Suite 118

Tucson, AZ 85701

Web Site

//www.azahcccs.gov/AHCCCS/

HealthcareAdvocacy/

The Office of Human Rights (OHR) is

part of the AHCCCS Division of Health

Care Advocacy and Advancement. OHR

provides advocacy to individuals deter-

mined to have a Serious Mental Illness

(SMI) to help them understand, pro-

tect and exercise their rights, facilitate

self-advocacy through education and ob-

tain access tobehavioral health services

in the publicly funded behavioral health

system in Arizona.

Additional Aspects of the

Appeal Process