Appeals and Grievance Initiation

A managed care system should provide consumers with an effective way to challenge any unfavorable decision made by a managed care organization (MCO).  Generally a consumer has two options — file a grievance for an internal review by the MCO, or request an appeal for review by the state.  In many cases, the appeal to the state is the better option, since the decision in an appeal is made outside of the MCO.

Appeals and grievances are not necessarily mutually exclusive — a consumer often has the right to pursue both.  Pursuing both options, however, may be more time consuming, and thus may not be the best course of action.

Contents – To access the full text, please click each sub-topic.

  • MCO must provide written notice to consumer on MCO’s decision to deny or reduce service, or deny payment: Wisconsin a
  • MCO must use the state-issued notice of action form: Wisconsin b
  • In responding to authorization requests, MCO must provide notice of action within 14 days of request, or within three business days of expedited service authorization request: Arizona c
  • MCO must notify consumer of service denial within 14 days with extension of up to 14 days if consumer or provider requests extension, or contract needs additional information and extension is in consumer’s interest: Kansas d
  • MCO must notify consumer of termination or reduction of services by at least 10 days before effective date: Kansas e
  • MCO must provide notices in consumer’s language if MCO has information that consumer has limited English proficiency: Arizona f
  • MCO must translate notice documents to prevalent non-English languages, or provide information on how information can be obtained in prevalent languages: Arizona g
  • Notice must include statement that written or oral translation is available for consumers who speak non-English languages: Wisconsin h
  • MCO must have written description of MCO’s complaint procedures available in prevalent non-English languages for major population groups identified by state, at no more than 6th grade reading level: Texas i
  • If grievance not decided in consumer’s favor, MCO must provide notice including right to request Medicaid fair hearing and to receive benefits while hearing is pending, and how to make request: Florida j
  • If MCO does not have independent external review organization for grievance process, MCO must give notice of right to appeal adverse decision to state’s Beneficiary Assistance Program (BAP). BAP will not consider appeal that has already been to Medicaid fair hearing: Florida k

  • Right to appeal any adverse action taken by MCO to deny, reduce, terminate, delay or suspend covered service as well as any other acts or omissions which impair quality, timeliness, or availability of such benefits: Tennessee l
  • Right to appeal denial or limited authorization of requested service including type or level of service; reduction, suspension or termination of previously authorized service; denial in whole or in part of payment for service; failure to provide services in timely manner; failure of MCO to comply with timeframes for dispositions of grievances and appeals; and denial of rural consumer’s request to obtain services outside MCO’s network when MCO is only MCO in area: Arizona m
  • Right to appeal denial of functional eligibility pursuant to long-term care functional screen; denial or limited authorization of requested service; reduction, suspension, or termination of previously authorized service; denial, in whole or in part, of payment for service; failure to provide services and support items in timely manner; failure of MCO to act within timeframes for resolution of grievances or appeals; development of consumer-centered plan that is unacceptable to consumer because it requires consumer to live in place that is unacceptable to consumer, does not provide sufficient care, treatment or support, or requires consumer to accept care, treatment or support items that are unnecessarily restrictive or unwanted; or notification by MCO of decision made in response to appeal that is entirely or partially adverse to consumer: Wisconsin n
  • Right to appeal denial or limitation of services requested by consumer or provider; denial of request for referral; decision that requested service is not covered benefit; reduction, suspension, or termination of already-authorized services; denial of payment for services; failure to provide timely services; failure to make grievance or appeal determinations within required timeframes: New York Partnership o
  • Right to appeal denial, limitation, reduction, suspension or termination of service, denial of payment, or failure to act in timely manner: Florida p
  • No right to appeal change in provider; change in rate MCO pays provider; termination of service authorized for limited number of units of service or duration of service; or adverse action resulting from change in state or federal law, although consumer has fair hearing right in regard to whether he or she is member of group impacted by change: Wisconsin q

  • Oral inquiries must be treated as appeals: Arizona r, New Mexico s, Texas t, Tennessee u
  • Oral appeal requests must be followed by signed, written requests: New Mexico v, Texas w
  • Grievance may be filed orally or in writing within one year of occurrence: Florida x
  • Appeal may be filed orally or in writing; when expedited resolution is required, oral request must be followed by written notice within 10 calendar days: Florida y
  • With consumer’s consent, appeal may be filed by any persons, including service provider or consumer-directed worker: Tennessee ``


  1. Wis. Contract, p 72.  (back)
  2. Wis. Contract, p. 148.  (back)
  3. Ariz. Contract, pp. 135-36.  (back)
  4. Kan. Contract, Atch. D., p. 4.  (back)
  5. Kan. Contract, Atch. D., p. 4.  (back)
  6. Ariz. Contract, p. 133.  (back)
  7. Ariz. Contract, p. 133.  (back)
  8. Wis. Contract, p. 150.  (back)
  9. Tex., Contract, p. 8-109.  (back)
  10. Fla. Contract, p. 100.  (back)
  11. Fla. Contract, p. 100.  (back)
  12. Tenn. Contract, p. 294.   (back)
  13. Ariz. Contract, p. 134.  (back)
  14. Wis. Contract, pp. 144-45.  (back)
  15. N.Y. Partnership Contract, App. K, p. 131.  (back)
  16. Fla., p. 97.  (back)
  17. Wis. Contract, p. 137.  (back)
  18. Ariz. Contract, p. 133.  (back)
  19. N.M. Contract, p. 79.  (back)
  20. Tex. Contract, p. 8-110.  (back)
  21. Tenn. Contract, p. 294.  (back)
  22. New Mexico: p. 79.  (back)
  23. Tex. Contract, p. 8-111.  (back)
  24. Fla. Contract, p. 99.  (back)
  25. Fla. Contract, p. 99.  (back)
  26. Tenn. Contract, p. 294.  (back)

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