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Appealing a Managed Care Organization (MCO) Decision

Authored By: Iowa Legal Aid

Information

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) or 515-327-7012 (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

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.  You can request a State Fair Hearing by:
•    going in person to your local DHS office;
•    telephone (DHS Appeals at 515-281-3094);
online at http://dhs.iowa.gov/node/966; or
•    in writing to:
Department of Human Services
Appeals Section
1305 E Walnut Street, 5th Floor
Des Moines, IA  50319
 
Phone (515) 281-3094
 
FAX (515) 564-4044
Email:  appeals@dhs.state.ia.us


Where can I get help with an Appeal?
You can contact Iowa Legal Aid.

 

 
If Iowa Legal Aid cannot help, look for an attorney on “Find A Lawyer” on the Iowa State Bar Association website iowabar.org.   A private attorney there can talk with you for a fee of $25 for 30 minutes of legal advice.
 
 
*As you read this information, remember this article is not a substitute for legal advice
  • Iowa Legal Aid provides help to low-income Iowans. 
    • To apply for help from Iowa Legal Aid:call 800-532-1275. 
    • Iowans age 60 and over, call 800-992-8161 or 
    • apply online at iowalegalaid.org

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Last Review and Update: Nov 04, 2021
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