Filing an Appeal
Internal Appeal Process
Filing an Appeal:
An appeal is a request for Magnolia to review a Magnolia Notice of Adverse Action. You can request an appeal by phone or in writing.
You will know that Magnolia Health is taking an action because we will send you a letter. The letter is called a notice of action. If you do not agree with the action, you may request an appeal.
Actions occur when Magnolia:
- Denies the care requested
- Decreases the amount of care
- Ends care that has previously been approved
- Denies payment for care and you may have to pay for it
- Denies the right to request services outside of the network (for residents of rural areas)
Who may file an Appeal?
- Parent or guardian of a minor member
- A person named by you
- A provider acting for your child
You must give written permission if someone else files an appeal for your child. Magnolia will include a form in the notice of action letter. Contact member services at 866-912-6285 (Relay 711) if you need help. We can assist you in filing an appeal.
When Does an Appeal Have to be Filed?
The Notice of Action will tell you about this process. You may file an appeal within 45 days of the receipt of the Notice of Action. If you make your request by phone or in person, you must also send Magnolia a letter confirming your request.
You may ask to keep receiving care related to your child’s review while we decide. You may have to pay for this care if the decision is not in your child’s favor.
Magnolia will give you a written decision within 15 days from the date of your request. If more than 15 days is needed to make a decision, we will send a letter to you. Magnolia will ask for extra time if more information is needed. The extra time may be better for your child’s case. If extra time is needed, the total grievance and appeal process timeframe may be extended to more than 90 days. The letter will say why we need more time.
You or your child’s provider may want us to make a fast decision. You can ask for an expedited review if you or your child’s provider feel that your child’s health is at risk. If you feel this is needed, call our clinical appeals coordinator at 866-912-6285 (Relay 711). We will make a decision within 72 hours of receipt of the appeal request, however, the review period may be up to 14 days. Magnolia may extend this review period up to 14 days if you request an extension, or if Magnolia determines that the extension is in your child’s best interest. You will also receive a letter telling the reason for the decision and what to do if you do not like the decision.
What if I am still dissatisfied with the outcome of my child’s grievance or appeal?
If you are still dissatisfied with the outcome of your child’s grievance or appeal, you may request a second level review. This request must be submitted in writing within 15 calendar days of receiving the grievance or appeal resolution from Magnolia Health. Your request must include a written statement containing an explanation of the grievance or appeal and reason you are dissatisfied with Magnolia’s decision. Magnolia will review your request and send a written decision to you within 15 calendar days of the receipt of the grievance or appeal.
If you remain dissatisfied with Magnolia’s decision on your grievance or appeal, you may request a third level review by sending Magnolia a written statement restating your grievance or appeal and the reasons for your dissatisfaction with Magnolia’s decision, along with any additional information needed for your grievance or appeal. This request must be made within 15 calendar days of receiving Magnolia’s decision for your second level review. Magnolia will provide a decision to you within 10 calendar days of receiving your third level request. Magnolia’s three (3) step process will allow a different person to review your request at each step. Your grievance or appeal will not be reviewed by the same person that reviewed your initial grievance or appeal.
For grievances, your initial review will be handled by Magnolia’s Grievance and Appeal Coordinator. If you request a second level review, your request will be reviewed by someone at a higher level than the Grievance and Appeal Coordinator, the Grievance and Appeals Manager. If you are dissatisfied with your second level review, your third level request will be reviewed by the Grievance Committee
For appeals, your initial review will be handled by Magnolia’s Appeals Coordinator. If you request a second level review, your request will be reviewed by a Medical Director that wasn’t involved in the initial decision. If you are dissatisfied with your second level review, your third level request will be reviewed by an Independent External Review Organization.