Appeals and Grievance Procedure

States generally set timelines for processing appeals and grievances, and may require a managed care organization (MCO) under some circumstances to continue benefits until an appeal or grievance is resolved.  Some states require MCOs to report appeals and grievance data.

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

  • 60 days to file appeal; if ruling is adverse, then 30 days to request fair hearing: Arizona a
  • 30 days to file appeal, with specified exceptions: Texas b
  • 90 days to request fair hearing: Florida c
  • In order to continue currently-authorized service, consumer must file appeal within 30 days from receipt of notice: Texas d
  • MCO must issue decision on expedited appeal within 3 business days, with decisions relating to hospitalizations made within one business day: Texas e
  • MCO must issue decision on expedited appeal within 72 hours after MCO receives appeal request, whether appeal was made orally or in writing: Florida f
  • MCO must issue written acknowledgement of receipt of grievance or appeal within 5 business days, except for expedited requests: Florida g
  • Consumer can examine case file ahead of time: Texas h
  • MCO must issue grievance determinations within 90 days, and non-expedited appeal determinations within 45 days: Florida i
  • Consumer has right to state appeal when consumer dissatisfied with MCO’s action on MCO internal appeal: Hawaii j
  • Extension up to 14 calendar days if consumer requests extension or if extension is in consumer’s interest: Texas k
  • MCO has option to have all grievance and appeal issues subject to external review processes by independent review organization: Florida l
  • Consumer has right to concurrent review by MCO and state: Massachusetts m
  • Consumer must exhaust MCO internal grievance system before using state’s fair hearing system: Hawaii n, New York o
  • Consumer has right to review by state Insurance Commissioner after exhausting both internal and state appeals: Hawaii p
  • Consumer must exhaust MCO’s internal process prior to complaints being made directly to state, but has right to request fair hearing at any time: Texas q

  • Right to expedited appeal when delay could “seriously jeopardize” consumer’s life or health: Florida r, New Mexico s, Texas t

  • Managed care grievance process includes access to state’s fair hearing process: Arizona u, Kansas v, New Mexico w, New York x
  • Hearings process must comply with Medicaid fair hearing regulations and Medicaid managed care regulations: Texas y
  • Request for fair hearing does not require exhaustion of other processes: Florida ``, Texas aa, Wisconsin bb
  • Fair hearing available at any time, unless consumer has requested expedited internal appeal: Kansas cc
  • Expedited fair hearing available only if consumer already has had expedited internal appeal: Kansas dd
  • If consumer chooses to exhaust MCO’s grievance and appeal process, he or she may still file for Medicaid fair hearing within 90 calendar days of receiving MCO’s notice of resolution: Florida ee

  • Grievance available to consumer for everything that is not “action”: Florida ff, Hawaii gg, Tennessee hh
  • Consumer can file complaint on MCO’s services, processes, procedures, and staff: Texas ii
  • Right to grievance or complaint: Massachusetts jj, New York kk
  • State “grievance review” process: Hawaii ll
  • Consumer has 180 days to file grievance: Kansas mm
  • MCO must resolve complaints within 30 calendar days after receipt unless consumer requests extension, or additional information needed and delay is in consumer’s interest: Texas nn
  • MCO has 30 business days to resolve grievance, with extension to 60 days for good cause: Kansas oo
  • MCO must conduct internal appeals processes in good faith despite existence of fair hearing process: New York pp
  • If complaint made to state, MCO must resolve within 10 business days, with extensions available for good cause: Texas qq
  • MCO must resolve grievance within 90 calendar days: Florida rr
  • Consumer can make complaint to state after exhaustion of internal grievance processes: Texas ss
  • MCO must have grievance system coordinator: Florida tt
  • Penalties against MCO for failure to resolve grievances or appeals timely: Kansas uu

  • MCO must continue benefits for duration of appeal process: Kansas vv, Massachusetts ww
  • MCO must continue benefits limited by duration of existing authorization, per current federal regulations: Arizona xx, Florida yy, Hawaii ```, Kansas aaa, Minnesota bbb, New Mexico ccc, New York ddd, Texas eee, Wisconsin fff
  • MCO has right to collect cost of benefits provided during appeal, if final resolution is adverse to consumer and services were furnished during appeal solely due to continuation of benefits requirement: Florida ggg

  • Decision-makers must be qualified with necessary clinical expertise: Arizona hhh, Florida iii, Kansas jjj, Texas kkk, Wisconsin lll
  • Decision-makers must not have been involved in original decision: Arizona mmm, Florida nnn, Kansas ooo, Texas ppp
  • Decision-makers must not have conflicts of interest: Wisconsin qqq
  • Grievance and appeal committee must include member of target population served by MCO: Wisconsin rrr

  • MCO must provide designated advocates to assist consumer in writing or filing appeal, and in monitoring appeal until issue is resolved: Texas sss
  • MCO must provide any reasonable help to consumer in completing forms and following procedures for filing grievance or appeal or requesting Medicaid fair hearing; this includes interpreter services, toll-free calling, and TTY/TTD capability: Florida ttt
  • MCO must provide consumer advocates to assist in navigating grievance system, making referrals to appropriate MCO staff, and facilitating resolution of issues: Tennessee uuu

  • MCO must submit to state quarterly reports that analyze trends, identify issues and providers that are the subject of appeals and grievances, and demonstrate how appropriate corrective actions will be identified and implemented: Wisconsin vvv
  • MCO must submit report to state regarding grievances and appeals: Hawaii www, Kansas xxx

  • MCO subject to remedies, including liquidated damages, if 2 percent of complaints are not resolved within 30 days: Texas yyy
  1. Ariz. Contract, p. 135.  (back)
  2. Tex. Contract, p. 8-110.  (back)
  3. Fla. Contract, p. 101.  (back)
  4. Tex. Contract, pp. 8-110 to 8-112.  (back)
  5. Tex. Contract, p. 8-113.  (back)
  6. Fla. Contract, p. 100-101.  (back)
  7. Fla. Contract, p. 97.  (back)
  8. Tex. Contract, p. 8-112.  (back)
  9. Fla. Contract, p. 99.  (back)
  10. Haw. RFP, p. 228.  (back)
  11. Tex. Contract, p. 8-113.  (back)
  12. Fla. Contract, p. 96.  (back)
  13. Mass. Contract, p. 49.  (back)
  14. Haw. RFP, p. 221.  (back)
  15. N.Y. Medicaid Advantage Plus Contract, Sect. 24, p. 1  (back)
  16. Haw. RFP, p. 231.  (back)
  17. Tex. Contract, pp. 8-109 and 8-114.  (back)
  18. Fla. Contract, p. 100-01.  (back)
  19. N.M. Contract, pp. 81-82.  (back)
  20. Tex. Contract, p. 8-113.  (back)
  21. Ariz. Contract, p. 51.  (back)
  22. Kan. Contract, Atch. D, p. 1.  (back)
  23. N.M. Contract, p. 80.  (back)
  24. N.Y. Medicaid Advantage Plus Contract, Sect. 14, p. 3; New York Partnership Contract, p. 128.  (back)
  25. Tex. Contract, p. 8-108.  (back)
  26. Fla. Contract, p. 101.  (back)
  27. Tex. Contract, p. 8-114.  (back)
  28. Wis. Contract, p. 162.  (back)
  29. Kan. Contract, Atch. D, p. 1.  (back)
  30. Kan. Contract, Atch. D, p. 1.  (back)
  31. Fla. Contract, p. 101.  (back)
  32. Fla. Contract, p. 97.  (back)
  33. Haw. RFP, p. 223.  (back)
  34. Tenn. Contract, p. 294.  (back)
  35. Tex. Contract, p. 8-44.  (back)
  36. Mass. Contract, p. 44.  (back)
  37. N.Y. Medicaid Advantage Plus Contract, App. F pp. 1-19; New York Partnership Contract, App. K, p. 124-37.  (back)
  38. Haw. RFP, p. 224.  (back)
  39. Kan. Contract, Atch. D, p. 2.  (back)
  40. Tex. Contract, p. 8-44.  (back)
  41. Kan. Contract, Atch. D, p. 2.  (back)
  42. N.Y. Medicaid Advantage Plus Contract, Sect. 24, p. 3.  (back)
  43. Tex. Contract, p. 8-108.  (back)
  44. Fla. Contract, p. 99.  (back)
  45. Tex. Contract, p. 8-109.  (back)
  46. Fla. Contract, p. 104.  (back)
  47. Kan. Contract, Atch. D, pp. 2, 7.  (back)
  48. Kan. Contract, Atch. D, p. 1.  (back)
  49. Mass. Contract, pp. 45, 49.  (back)
  50. Ariz. Contract,  p. 138.  (back)
  51. Fla. Contract, pp. 101-102.  (back)
  52. Haw. RFP, p. 230.  (back)
  53. Kan. Contract, Atch. D, pp. 1, 6.   (back)
  54. Minn. Contract, p. 182-83.  (back)
  55. N.M. Contract, p. 80.  (back)
  56. N.Y. Medicaid Advantage Plus Contract, Sect. 24, p. 2.  (back)
  57. Tex. Contract, p. 8-112.  (back)
  58. Wis. Contract, p. 148.  (back)
  59. Fla. Contract, p. 102.  (back)
  60. Ariz. Contract, p. 134.  (back)
  61. Fla. Contract, p. 97.  (back)
  62. Kan. Contract, Atch. D, p. 1.  (back)
  63. Tex. Contract, pp. 8-110 to 8-111.  (back)
  64. Wis. Contract, p. 156.  (back)
  65. Ariz. Contract, p. 134.  (back)
  66. Fla. Contract, p. 97.  (back)
  67. Kan. Contract, Atch. D, p. 1.  (back)
  68. Tex. Contract, pp. 8-110 to 8-111.  (back)
  69. Wis. Contract, p. 156.  (back)
  70. Wis. Contract, p. 156.  (back)
  71. Tex. Contract, pp. 8-111.  (back)
  72. Fla. Contract, p. 99.  (back)
  73. Tenn. Contract, p. 368.  (back)
  74. Wis. Contract, p. 165-66.  (back)
  75. Haw. RFP, p. 258-59.  (back)
  76. Kan. RFP, p. 101.  (back)
  77. Tex. Contract, pp. 8-44.  (back)

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