Complaints and Appeals
MHS and your doctor believe it is very important for you to receive the quality healthcare you need in a timely manner. There may be times when you need to tell us if you are not satisfied with MHS programs and services, or services provided by MHS or your doctor. Or, you may disagree with a decision that MHS made, regarding your healthcare.
MHS takes your complaints seriously. We record your complaint, and follow up with you about how we can serve you better. If you are still not satisfied with the way your complaint is handled or it is not resolved within 24 hours, you can take the next step by filing a grievance. You can call MHS Member Services at 1-877-647-4848 (TTY: 1-800-743-3333) to make a complaint.
A grievance is when you are not happy with previous care or service provided by MHS or your doctor and you want us to investigate. Examples of something you might not be happy about are:
- The quality of care or services provided.
- Conduct such as rudeness of a provider or employee.
- Not respecting member rights.
An appeal is when you, your provider, or your representative are not satisfied with the result of a decision made by MHS and wish to take action. This may be because you are not happy with the results of a grievance you filed, OR because you are not happy with a decision MHS made when your doctor asked for prior authorization or prior approval for some treatment, therapy, medical equipment or other medical service. To name a representative or your provider, send MHS a signed letter or consent form telling us who will be your representative.
If waiting the regular time for the answer to the appeal would put you at risk of serious bodily harm or injury, you may ask MHS to consider doing an extra fast review. This is called “expedited review.” To ask for expedited review, call or write to MHS as soon as possible. MHS resolves expedited reviews within two calendar days (48 hours).
External, independent reviews may be requested for decisions made by MHS Medical Management or MHS Utilization Management:
- based on medical necessity, or
- that the service being requested is experimental or investigational.
To request a review, call or write to MHS within 60 calendar days of your appeal decision. MHS will send the complete case file to an external, independent review agency that is registered with the Indiana Department of Insurance and who has no connection to MHS. The independent review agency will have a same specialty physician review the case. They will send their answer to the member and to MHS in about two weeks. MHS will pay for this review. The member may ask for both an external, independent review and a State Fair Hearing, but not at the same time.
State Fair Hearing
After an appeal or, after the external independent review, you may ask for a State Fair Hearing at the Indiana Family and Social Services Administration. For help requesting a State Fair Hearing, contact Member Services at 1-877-647-4848 or write to the FSSA directly within 33 days of exhausting MHS appeal procedures: Hearings and Appeals Section, MS-04, Indiana Family and Social Services Administration, 402 West Washington Street, Room E034, Indianapolis, IN 46204
Care During Appeals
You are still our member. You will continue to get all covered healthcare services for your benefit package. And, MHS will continue to cover the care you are appealing until the final decision is made. If the final decision on your appeal is to deny the services, you may have to pay.
If MHS makes a decision about your care and you disagree, as an MHS member, you have a right to ask us to review the decision:
- You may write or call MHS to file an appeal and ask us to review the decision. You must contact us within 60 calendar days from the date MHS made its decision. If you miss that deadline, you will not be able to have the case reviewed.
- You may ask MHS to help you. If you call us, MHS will help you by filling out a member appeal.
- You may send MHS medical documentation, statement or other evidence, or any allegations of fact or conclusions of law you think we should know. You may ask your treating physician or your primary care doctor to send us information you think we should have.
- You may ask someone to represent you, like your doctor or a lawyer, a family member or another person you trust. To name a representative, send MHS a signed letter or note telling us the name of the person, your relationship with the person, and how to call or write to them. You don’t have to name a representative if you don’t want to.
- You may ask MHS to continue paying for the medical services that we denied while your case is being reviewed. You must contact MHS within 10 days of getting your original denial letter to make this request. Please be aware that you may be required to pay the cost of services provided while your case is pending, if the final decision is not in your favor.
- If you believe that waiting the regular time for the answer to your appeal will harm your life or health, you may ask MHS to consider doing an extra-fast review of your case, called an “expedited review.” You must ask for this as soon as possible by calling or writing to MHS.
- You may participate in resolving your case by contributing paperwork you would like reviewed and by meeting with the panel that is reviewing your case, either in person or on the phone. You must let us know your plan to participate in advance when you call or write to us. You may have the person that you named to represent you, join you in participating in the resolution of your case.
- You may review any medical records MHS has on file for you, and you may review your case file both before and during the appeal process, free of charge. To ask to see the information, please call or write to MHS.
- You may contact MHS Member Services to check on the status of your case by phone at 1-877-647-4848 or online at mhsindiana.com/contact-us.
- If you are not satisfied with the results of the MHS review of your case, you have the right to go to the next level of appeal including Independent Review, State Fair Hearing, or both.
The MHS member ombudsman program is a partnership between MHS and Mental Health America of Indiana. An ombudsman is someone who works to help you get a problem solved. MHS members can contact an ombudsman for free to discuss any problems they may be having with MHS, MHS services, MHS doctors or any other part of their healthcare. The ombudsman is neutral, so they do not side with MHS or the Medicaid program. The ombudsman will work with you to get your problem solved. If you are an MHS member (or a legal representative), please call if:
- You have unresolved questions about your MHS benefits or services.
- You want to know what your MHS rights and responsibilities are for your MHS coverage.
- You need assistance with the appeals process, including filling out the proper paperwork, documenting verbal appeals or guidance through the appeals process.
If you want the assistance of an ombudsman, please call them toll-free at 1-877-647-5326, 8 a.m. - 8 p.m. Monday through Friday.
Read more in our Member Ombudsman brochure on the Brochures & Guides page.