Appeals And Grievances

GRIEVANCES AND APPEALS

You may not always be happy with Harmony Health Plan. We want to hear from you. Harmony Health Plan has people who can help you. Harmony Health Plan cannot take your benefits away because you make a grievance, appeal, or ask for a State Fair Hearing.

There are two ways to tell Harmony Health Plan about a problem:

Grievance or Appeal

A Grievance is a way for you to show dissatisfaction about things like:

• The quality of care or services you received;
• The way you were treated by a provider; or
• A disagreement you may have with a MO HealthNet Managed Care health plan policy.

An Appeal is a way for you to ask for a review when your MO HealthNet Managed Care health plan takes action to:

• Deny or give a limited approval of a requested service;
• Deny, reduce, suspend, or end a service already approved;
• Deny payment for a service; or fails to:
• Act within required time frames for getting a service;
• Make a grievance decision within thirty (30) days of receipt of request;
• Make an expedited decision within three (3) days of receipt of request;
• Make an appeal decision within forty-five (45) days of receipt of request.

Harmony Health Plan must give you a written Notice of Action if any of these actions happen. The Notice of Action will tell you what we did and why, and give you your rights to appeal or ask for a State Fair Hearing.

You Have Some Special Rights When Making A Grievance Or Appeal:

1. A qualified clinical professional will look at medical grievances or appeals.
2. If you do not speak or understand English, call 1-866-822-1340 to get help from someone who speaks your language.
3. You may ask anyone such as a family member, your minister, a friend, or an attorney to help you make a grievance or an appeal.
4. If your physical or behavioral health is in danger, a review will be done within 3 working days or sooner.This is called an expedited review. Call Harmony Health Plan and tell Harmony Health Plan if you think you need an expedited review.
5. >Harmony Health Plan may take up to 14 days longer to decide, if you request the change of time, or if we think it is in your best interest. If Harmony Health Plan changes the time, we must tell you in writing the reason for the delay.
6. If you have been getting medical care and your MO HealthNet Managed Care health plan reduces, suspends, or ends the service, you can appeal. In order for medical care not to stop while you appeal the decision, you must appeal within 10 days from the date the Notice of Action was mailed, and tell us not to stop the service while you appeal. If you do not win your appeal, you may have to pay for the medical care you got during this time.
7. You may request enrollment in another MO HealthNet Managed Care health plan if the issue cannot be resolved.

How To Make A Grievance Or Appeal Or Ask For A State Fair Hearing:

1. GRIEVANCE—You may file a grievance on the telephone, in person, or in writing. Call Harmony Health Plan at 1-866-822-1340 to file a grievance.

   Harmony Health Plan will write you within 10 days and let you know we got your grievance.

   Harmony Health Plan must give written notice of a decision within 30 days.

2. APPEAL—You may file an appeal orally or in writing to Harmony Health Plan. Unless you need an expedited review, you must complete a written request even if you filed orally.
   • You must appeal within 90 days from the date of our Notice of Action.
   • For help on how to make an appeal, call Harmony Health Plan at 1-866-822-1340.
     Send your written appeal to:
     Harmony Health Plan of Missouri
     P.O. Box 31370
     Tampa, FL 33631-3370
   • Harmony Health Plan must write you within 10 days and let you know we got your appeal.
   • Harmony Health Plan must give written notice of a decision within 45 days, unless it is an expedited review.
3. STATE FAIR HEARING—You have the right to ask for a State Fair Hearing when your MO HealthNet Managed Care health plan takes an action, or when your appeal is not decided in your favor. You may ask for a State Fair Hearing orally or in writing. Unless you need an expedited review, you must complete a written request even if you asked orally.
   • You must ask for a State Fair Hearing within 90 days from the date of the MO HealthNet Managed Care health plan’s written Notice of Action or Appeal Decision Letter.
   • For help on how to ask for a State Fair Hearing, call the MOHealthNet Division at 1-800-392-2161.
   • If you do not speak or understand English, call 1-800-392-2161 to get help from someone who speaks your language.
   • You can send your written request to:
     Participant Services Unit, MO HealthNet Division
     P.O. Box 6500
     Jefferson City, MO 65102-6500
   • You will be sent a form to complete. Once you send the form back, a date will be set for your hearing.
   • You may ask anyone such as a family member, your minister, a friend, or an attorney to help you with a State Fair Hearing.
   • A decision will be made within 90 days from the date you asked for a hearing.
   • >If your physical or behavioral health is in danger, a decision will be made within 3 working days. This is called an expedited hearing. Call 1-800-392-2161 if you think you need an expedited hearing.
   • If you have been getting medical care and your MO HealthNet Managed Care health plan reduces, suspends, or ends the service, you can ask for a State Fair Hearing. In order for medical care not to stop, you must ask for a State Fair Hearing within 10 days of the date the written notice of action was mailed, and tell us not to stop the service while you appeal. If you do not win, you may have to pay for the medical care you got during this time.