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Grievances and Appeals

You may not always be happy with Missouri Care. We want to hear from you. Missouri Care has people who can help you. Missouri Care cannot take your benefits away because you make a grievance, appeal, or ask for a State Fair Hearing. 

Call Member Services at 1-800-322-6027 (TTY 711) for help. We’re here for you Monday-Friday from 8 a.m. to 6 p.m. You may also send a letter to Member Services at:

Missouri Care 
4205 Philips Farm Road, Suite 100 
Columbia, MO 65201


There are two (2) ways to tell Missouri Care about a problem:

GRIEVANCE or APPEAL

A grievance is a way for you to show dissatisfaction about things like: 

• The quality of care or services you received;
• The way you were treated by a provider;
• A disagreement you may have with a MO HealthNet Managed Care health plan policy;
• You do not agree to the extension of time requested for a decision of a grievance or an appeal; or
• You do not agree to the extension of time requested by your MO HealthNet Managed care health plan to make an authorization decision 

An appeal is a way for you to ask for a review when your MO HealthNet Managed Care health plan makes an adverse benefit determination to:

• Deny or give a limited approval of a requested service;
• Deny, reduce, suspend or end a service already approved; or
• Deny payment for a service. 

Or fails to: 

• Act within required time frames for getting a service;
• Make a grievance resolution within thirty (30) calendar days of receipt of request;
• Make an expedited decision within seventy-two (72) hours of receipt of request; or
• Make an appeal resolution within thirty (30) calendar days of receipt of request. 

Missouri Care must give you a written Notice of Adverse Benefit Determination if any of these actions happen. The Notice of Adverse Benefit Determination will tell you what we did and why and give you your rights to appeal and ask for a State Fair Hearing.


YOU HAVE SOME SPECIAL RIGHTS WHEN MAKING A GRIEVANCE OR APPEAL

1. A qualified clinical professional will look at medical grievances or appeals.

2. If you do not speak or understand English, call 1-800-322-6027 (TTY 711) to get help from someone who speaks your language. 

3. You may ask anyone such as a family member, your minister, a friend, your provider, authorized representative or an attorney to help you make a grievance or an appeal. 

4 .If your physical or behavioral health is in danger, a review will be done within seventy-two (72) hours or sooner. This is called an expedited review. Call Missouri Care and tell Missouri Care if you think you need an expedited review. 

5. Missouri Care may take up to fourteen (14) calendar days longer to decide if you request the change of time or if we think it is in your best interest. If Missouri Care changes the time, we must tell you in writing the reason for the delay. 

6. If you have been getting medical care and your MO HealthNet Managed Care health plan reduces, suspends or ends the service, you can appeal. In order for medical care not to stop while you appeal the decision, you must appeal within ten (10) calendar days from the date the Notice of Adverse Benefit Determination was mailed and tell us not to stop the service while you appeal. If you do not win your appeal, you may have to pay for the medical care you got during this time. 

7. You may request enrollment in another MO HealthNet Managed Care health plan if the issue cannot be resolved.


HOW TO MAKE A GRIEVANCE OR APPEAL AND ASK FOR A STATE FAIR HEARING

1. Grievance

You may file a grievance by telephone, in person or in writing. Call Missouri Care at 1-800-322-6027 (TTY 711) to file a grievance.

• Missouri Care will write you within ten (10) calendar days to let you know we got your grievance.
• Missouri Care must give written notice of a decision with thirty (30) calendar days.

2. Appeal

You may file an appeal orally or in writing to Missouri Care. Unless you need an expedited review, you must complete a written request even if you filed orally. • You must appeal within sixty (60) calendar days from the date of our Notice of Adverse Benefit Determination. 

• For help on how to make an appeal, call Missouri Care at 1-800-322-6027 (TTY 711).
• Send your written appeal to:

Missouri Care
Attn: Complaints and Appeals Analyst
4205 Philips Farm Road, Suite 100
Columbia, MO 65201

3. State Fair Hearing

You have the right to ask for a State Fair Hearing when your MO HealthNet Managed Care health plan appeal process is complete and your appeal is not decided in your favor. You may ask for a State Fair Hearing orally or in writing. Unless you need an expedited review, you must complete a written request even if you asked orally.

• You must ask for a State Fair Hearing within one hundred twenty (120) calendar days from the date of the MO HealthNet Managed Care health plan’s written Notice of Appeal Resolution.
• For help on how to ask for a State Fair Hearing, call the MO HealthNet Division at 1-800-392-2161.
• If you do not speak or understand English, or need American Sign Language, call 1-800-392-2161 to get help from someone who speaks your languages at no cost to you. This includes auxiliary aids and services. Members who use a Telecommunications Device for the Deaf (TDD) can call 1-800-735-2966. These services are available to you at no cost.

You can send your written requests to:

MO HealthNet Division 
Stakeholders Services 
Participant Services Unit 
P.O. Box 6500 
Jefferson City, MO 65102-6500

Or fax to 1-573-526-2471

• You will be sent a form to complete. Once you send the form back, a date will be set for your hearing.
• You may ask anyone such as a family member, your minister, a friend or an attorney to help you with a State Fair Hearing.
• A decision will be made within ninety (90) calendar days from the state agency’s receipt of a State Fair Hearing request.
• If your physical or behavioral health is in danger, a decision will be made within three (3) business days. This is called an expedited hearing. Call 1-800-392-2161 if you think you need an expedited hearing.
• If you have been getting medical care and your MO HealthNet Managed Care health plan reduces, suspends or ends the service, you can ask for a State Fair Hearing. In order for medical care not to stop, you must ask for a State Fair Hearing within ten (10) calendar days of the date the written Notice of Appeal Resolution was mailed and tell us not to stop the service while you appeal. If you do not win, you may have to pay for the medical care you got during this time.


Grievances and Appeals

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State Approved: 06/22/2016 MOC16078 Last Updated On: 7/18/2018