Complaints and Appeals
We hope you will always be happy with us and our network providers. If you are not happy, 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:
- Grievance and complaint process
- Internal appeal process
- Access to Medicaid State Fair Hearing
Magnolia maintains records of each grievance, complaint and appeal filed by our members or by their authorized representatives, and the responses to each grievance, complaint and appeal, for a period of ten (10) 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 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:
111 East Capitol Street, Suite 500
Jackson, MS 39201
If you file a written grievance, the Grievance Coordinator will send you a letter within five (5) calendar days letting you know that 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.
There will be no retaliation against you or your representative for filing a grievance or complaint with Magnolia.
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.
Internal Appeal Process
An appeal is a request for Magnolia to review an Adverse Benefit Determination. You can request this review by phone or in writing.
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)
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.
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. If you make your request by phone or in person, you must also send Magnolia a letter confirming your request for standard appeal within thirty (30) calendar days. 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.
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.
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.
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.
Medicaid State Fair Hearing for Appeals
What if I am still not pleased?
If you are still dissatisfied with the outcome of your appeal with Magnolia, you or your provider may request a State Fair Hearing conducted by the Division of Medicaid (DOM) only after you have received your final appeal resolution from Magnolia. This request must be submitted in writing within 120 calendar days from the date on the final Notice of Appeal Resolution from Magnolia.
If you request a State Fair Hearing and want your benefits to continue, you must file your request within ten (10) calendar days from the date you receive our final 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:
Mississippi Division of Medicaid
Attn: Office of Appeals
550 High Street, Suite 1000
Jackson, Mississippi 39201
Ph: 601-359-6050 or 1-800-884-3222