Complaints and Appeals

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 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.  A member may file a grievance either orally or in writing with Magnolia any time after the grievance has occurred.

Examples of a grievance:

• Failure to respect your rights
• The quality of care or services provided
• Aspects of interpersonal relationships such as rudeness of a provider or an employee

A complaint is an expression of dissatisfaction that is of less serious or formal nature that is resolved within one (1) calendar day of receipt.    Complaints may be received orally or in writing and may be submitted to Magnolia by you or your authorized representative, including your provider.  Complaints must be submitted to Magnolia within thirty (30) days of the date of the event causing dissatisfaction.

Filing a grievance or complaint will not affect your healthcare services. We want to know your concerns so we can improve our services.

To file a grievance or complaint, call Member Services at 1-866-912-6285. Magnolia will provide reasonable assistance to members in filing a grievance or complaint. You can also write a letter and mail or fax your grievance or complaint 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 unhappy with
• What you would like to have happen

A grievance or complaint may be filed in writing or by mailing it to the address below or by faxing it to 1-877-264-6519. You can also call us at 1-866-912-6285 or file the grievance or complaint in person at:

Magnolia Health

Grievance Coordinator

111 East Capitol Street, Suite 500

Jackson, MS 39201

If you file a grievance, either oral or written, the Grievance Coordinator will send you a letter within five (5) calendar days letting you know we have received your grievance and include the expected date of resolution.

If you file a complaint, there is no need for written acknowledgement.

If someone else is going to file a grievance or complaint for you, we must have your written permission for that person to file your grievance or complaint. 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 complaint to someone else. A provider acting for you can file a grievance or complaint for you with your written consent.

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 grievance.

You can expect a resolution and a written response from Magnolia within thirty (30) calendar days of receiving your grievance.  Magnolia may extend by up to fourteen (14) calendar days if the member requests the extension, or if Magnolia determines that there is a need for additional information and the extension is in the member’s best interest.  For any extension not requested by the member, Magnolia shall give the member written notice of the reason for the extension within two (2) calendar days of the decision to extend the timeframe. If you disagree with Magnolia’s decision for an extension, you may file a grievance regarding the dissatisfaction.  

There will be no retaliation against you or your representative for filing a grievance or complaint with Magnolia.

Expedited Grievances

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, please contact Magnolia for a review and investigation by the appropriate clinical staff.  Clinically urgent grievances will be resolved within seventy-two (72) hours of receipt.

An appeal is a request for Magnolia to review an Adverse Benefit Determination.   Within ten (10) calendar days, Magnolia will send you a letter, letting you know your appeal was received and give you an expected date that the appeal will be resolved.

An Adverse Benefit Determination occurs when Magnolia:

• Denies or limits authorization of a service you want
• Decreases, suspends, or ends care that you are already getting
• Denies all or part of payment for covered care and you may have to pay for it
• Fails to provide services in a timely manner as defined by the state
• Denies the right to request services outside the network (for residents in rural areas)
• Denies a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.

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.  You can request an appeal by phone or in writing.

• You, the member (or the parent or guardian of a minor member)
• Any person named by you (Authorized Representative)
• 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 Benefit Determination Notice. Contact Member Services at 1-866-912-6285 if you need help. We can assist you in filing an appeal.

• Member Appeals Authorized Representative Form (PDF)

The Adverse Benefit Determination Notice will tell you about this process. You may file an appeal within sixty (60) calendar days of the date on the Adverse Benefit Determination Notice. Within ten (10) calendar days, Magnolia will send you a letter, letting you know your appeal was received and give you an expected date that the appeal will be resolved.

You may present evidence and examine the case file and other documents related to the appeal in person, as well as in writing.  You may examine your case file, including medical records and any other documents and records used during the appeals process.  Copies will be given to you at no cost at your request.

Continuation of Benefits

If all of the following are met, you may ask to keep getting care (benefits) related to your Appeal while we decide:

1. You file a timely Appeal of an Adverse Benefit Determination.  Timely filing means filing for benefits to continue on or before whichever date is later, 10 days from the date on the Adverse Benefit Determination letter, or the date of the proposed Adverse Benefit Determination
2. The Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
3. The services were ordered by an authorized service Provider;
4. The time period covered by the original authorization has not expired; and
5. You requests extension of the benefits.

If, at your request, Magnolia Health continues or reinstates your benefits while the appeal or state fair hearing is pending, the benefits must be continued until one of following occurs:

1. You withdraw the appeal or request for state fair hearing.
2. You fail to request a state fair hearing and continuation of benefits within 10 calendar days after Magnolia sends the notice of an adverse resolution to the enrollee's appeal under § 438.408(d)(2).
3. A State fair hearing office issues a hearing decision adverse to the enrollee.

If the final decision is to uphold Magnolia Health's adverse benefit determination, Magnolia may, recover the cost of services furnished to you while the appeal and state fair hearing was pending. In other words, you may have to pay for this care if the decision is not in your favor.

You may request to extend the time for more than sixty (60) calendar days to file an appeal.  This request must be given in writing and tell why the request was not filed within the 60 days.

Magnolia will give you a written decision within thirty (30) calendar days from the date of your request.  The decision will be made by a reviewer with the appropriate expertise.  If more than thirty (30) days is needed to make a decision, we will send a letter to you. Magnolia may extend the thirty (30) calendar day timeframe by fourteen (14) calendar days if you request the extension, or Magnolia decides that more information is needed, and will give you written notice of the extension within two (2) calendar days of the decision to extend the timeframe.

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.   If an expedited appeal is made by phone, follow-up with a written, signed appeal is not required.

We will decide within 72 hours of receipt of the expedited appeal request. However, Magnolia may extend up to fourteen (14) calendar 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. If you disagree with Magnolia’s decision for an extension, you may file a grievance regarding the dissatisfaction.  

Expedited appeals do not require a signed authorization form.

Magnolia will make reasonable efforts to provide and document verbal notice of an expedited appeal resolution.