Complaints and Appeals
We hope you will always be pleased with us and our network providers. If you are not pleased, please let us know. Magnolia has steps for handling any problems you may have. Magnolia offers all of our members the following processes to achieve member satisfaction:
- Internal grievance process
- Internal appeal process
- Access to Medicaid State Fair Hearing
Magnolia maintains records of each grievance and appeal filed by our members or by their authorized representatives, and the responses to each grievance and appeal, for a period of ten years.
Magnolia wants to fully resolve your problems or concerns. Magnolia will not hold it against you or treat you differently if you file a grievance. A grievance is an expression of dissatisfaction about any matter or aspect of Magnolia operation, other than an adverse benefit determination. Grievances may be received orally or in writing and may be submitted to Magnolia by you or your authorized representative, including your provider. Grievances must be submitted to Magnolia within 30 days of the date of the event causing dissatisfaction.
Filing a grievance will not affect your healthcare services. We want to know your concerns so we can improve our services.
To file a grievance, call member services at 866-912-6285 (Relay 711). Magnolia will provide reasonable assistance to members in filing a grievance. You can also write a letter and mail or fax your grievance to Magnolia at 1-877-264-6519. Be sure to include:
- Your first and last name
- Your Medicaid ID number
- Your address and telephone number
- What you are not pleased with
- What you would like to have happen
Grievance and Appeal Coordinator
111 East Capitol Street, Suite 500
Jackson, MS 39201
If you file a written grievance, the Grievance and Appeal Coordinator (GAC) will send you a letter within five (5) business days letting you know that we have received your grievance. If you submit your grievance by phone or in person, there is no need for written acknowledgement.
If someone else is going to file a grievance for you, we must have your written permission for that person to file your grievance or appeal. You can call member services to receive a form or go to www.magnoliahealthplan.com. This form gives your right to file a grievance or appeal to someone else. A provider acting for you can file a grievance or appeal for you.
If you have any proof or information that supports your grievance, you may send it to us and we will add it to your case. You may supply this information to Magnolia by including it with a letter, by sending us an email or a fax, or by bringing it to Magnolia in person. You may also request to receive copies of any documentation that Magnolia used to make the decision about your care, grievance, or appeal.
To review your request, we may need to obtain additional information. If a signed Authorization to Release Information Form is not included with your grievance, a form will be sent to you for signature. If a signed authorization is not provided within 30 business days of the request, Magnolia may issue a decision on the grievance without review of some or all of the information. When a signed request is received by your authorized representative, appropriate proof of your designation must be provided.
You can expect a resolution and a written response from Magnolia within 30 days of receiving your grievance. If Magnolia needs more than 30 days to resolve the grievance, 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 case. Magnolia will ask for the extra 14 days in writing. The letter will say why we need more time. Members may also request an extra 14 days.
There will be no retaliation against you or your representative for filing a grievance or appeal with Magnolia.
Filing a grievance will not affect your health care services.
Internal Appeal Process
An appeal is a request for Magnolia to review an Magnolia Adverse Benefit Determination Notice. You can request this review by phone or in writing.
You will know that Magnolia is taking an action because we will send you a letter. The letter is called an Adverse Benefit Determination notice. 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)
- You, the member (or the parent or guardian of a minor member).
- A person named by you.
- A provider acting for you.
You must give written permission if someone else files an appeal for you. Magnolia will include a form in the Adverse Benefits Determination letter. Contact member services at 866-912-6285 (Relay 711) if you need help. We can assist you in filing an appeal.
The Adverse Benefit Determination notice will tell you about this process. You may file an appeal within 60 calendar days from the date on Magnolia's Adverse Benefit Determination notice. 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 getting care related to your review while we decide. You may have to pay for this care if the decision is not in your favor.
Magnolia will give you a written decision within 30 calendar days from the date of your request. If more than 30 calendar 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 case. Magnolia will ask for the extra 14 days in writing. The letter will say why we need more time.
You or your provider may want us to make a fast decision. You can ask for an expedited review if you or your provider feel that your health is at risk. If you feel this is needed, call our Clinical Appeals Coordinator at 866-912-6285 (Relay 711).
We will decide within 72 hours of receipt of the appeal request. However, the review period may be up to 14 days. Magnolia may extend up to 14 days if you request an extension, or if Magnolia determines that the extension is in your best interest. You will also receive a letter telling the reason for the decision and what to do if you don’t like the decision.
Medicaid State Fair Hearing for Appeals
What if I am still not pleased?
If you are still dissatisfied with the outcome of your appeal, you may request a State Fair Hearing conducted by the Division of Medicaid only after you have received your final appeal resolution with Magnolia. This request must be submitted in writing within 120 calendar days from the date of Magnolia's notice of resolution (appeal denial letter).
You or your provider may request a State Fair Hearing within 120 calendar days from the date of Magnolia's notice of resollution (appeal denial lettter). If you request a State Fair Hearing and want your benefits to continue, you must file your request within 10 days from the date you receive our decision. If the State Fair Hearing finds that Magnolia’s decision was right, you may be responsible for the cost of the continued benefits.
To request a State Fair Hearing, please write to:
Division of Medicaid, Office of the Governor
Attn: Office of Appeals
550 High Street, Suite 1000
Jackson, Mississippi 39201
Ph: 601-359-6050 or 1-800-884-3222