Appealing a Managed Care Organization (MCO) Decision

Iowa Medicaid has switched to Managed Care.  Almost everyone who has Medicaid in Iowa is now assigned to a Managed Care Organization.  Managed Care Organizations are also called MCOs.  Your MCO will send you notices of their decisions from time to time.  Those decisions are called Notices of Action.  Sometimes an MCO may make a decision that you disagree with.  If this happens, you may file an appeal.

What may I appeal?

These are the things you may appeal:

• The MCO denies or limits authorization of a requested service, including the type or level of service;
• The MCO reduces, suspends, or terminates a service that they previously authorized;
• The MCO denies partial or whole payment of a service;
• The MCO fails to provide services in a timely manner (as defined by DHS);
• The MCO fails to act within required time frames; and the MCO denies a Medicaid recipient’s request to get services from a provider outside the MCO’s network.  This only applies to residents of rural areas where there is only one appropriate provider of a needed service.

How do I file an appeal?

Each MCO has information on its website about how to file an appeal.  This information should also be in the member handbook provided to you.

Appeals must be filed within a certain time period.  Medicaid members have 60 days from the Notice of Action to file the appeal.  The MCO will look at the appeal and make a decision.  If you disagree with the MCO’s appeal decision, then you may ask for a State Fair Hearing.  A State Fair Hearing is a higher level of appeal.

To file an appeal with your MCO:

Amerigroup You can appeal by:

1. Calling at 1-800-600-4441 (TTY 711). If you appeal on the phone, you must follow up with a written appeal within 10 calendar days of when you call; or
2. Sending an appeal in writing to:
   Grievances and Appeals Department
   Amerigroup Iowa, Inc.
   4800 Westown Parkway, Ste. 200
   West Des Moines, IA 50266

Amerigroup will respond with a decision within 30 days from when they receive your appeal for non-expedited appeals and 72 hours for expedited appeals. Note that Amerigroup requires written consent for a third party to file an appeal on behalf of a Medicaid member.

Iowa Total Care You can appeal by:

1. Calling Member Services. The toll-free phone number is 1-833-404-1061 (TTY:711)
2. Sending by fax to 1-833-809-3868
3. In person or by mail:
   Iowa Total Care, Attn: Appeals
   1080 Jordan Creek Parkway, Suite 100 South
   West Des Moines, IA 50266

Molina Healthcare of Iowa You can appeal by:

1. Calling Member Services. The toll-free phone number is 1-844-236-0894 (TTY:711)
2. Sending by fax to 1-888-832-1922
3. In person or by mail:
   Molina Healthcare of Iowa
   P.O. Box 93010
   Des Moines, IA 50393

Molina Healthcare will respond with a decision within 30 days from when they receive your appeal for non-expedited appeals and 72 hours for expedited appeals.

What if I don’t agree with the appeal decision?

If you do not agree with the MCO’s decision, you may ask for a State Fair Hearing.  You must request a State Fair Hearing within 120 days of the MCO’s appeal decision.  At a State Fair Hearing, there will be an administrative law judge who makes a decision after a hearing.  For more information about appeals, see  https://hhs.iowa.gov/programs/appeals You can request a State Fair Hearing by:

• going in person to your local HHS office;
• telephone (HHS Appeals at 888-723-9637);
• online at https://secureapp.dhs.state.ia.us/dhs_titan_public/appeals/appealrequest; or
• in writing to:
• Department of Health and Human Services
  Appeals Section
  321 E 12th Street
  Des Moines, IA  50319
• Phone 888-723-9637
• FAX 515-564-4044
• Email: appeals@hhs.iowa.gov

Where can I get help with an Appeal?

You can contact Iowa Legal Aid.