If you have a problem with your health care or services, you have a right to file a grievance or appeal.  

We can help you understand grievances, appeals, external review, and state fair hearings. We can also help you in file a grievance or appeal. And we can help you get ready for a state fair hearing.

A grievance is a complaint you file when you are unhappy with your health care. It may be about the quality of care, how you were treated, or that your rights were not respected. You can file a grievance at any time.

An expedited (fast) grievance is when you ask your MCE to quickly resolve the grievance because waiting 30 days could harm your life, health, or ability to function. If the MCE agrees with the request, they must resolve the grievance within 48 hours.

We can help you with grievances:

  • We educate you on the grievance process.
  • We listen to you.
  • We help you decide if you want to file a standard or expedited grievance.
  • We record your complaint and ask you to confirm the information is correct.
  • We file a grievance on your behalf if you ask us to.
  • We answer your questions about a grievance you asked us to help with.

An appeal is when you ask your MCE to change their decision to deny or reduce a health care service. This is called an “adverse benefit determination.” You have 60 days from the date of the decision to file an appeal.

An adverse benefit determination is when the MCE:

  • Denies or provides limited approval for a requested service.
  • Reduces, suspends, or terminates (ends) a previously approved service.
  • Denies payment for care or approves payment for less care than you asked for.
  • Lowers the number of services you can get or stops paying for an approved service.
  • Denies all or part of a payment for services.
  • Did not give services in a timely way.
  • Did not act in the required time.
  • Denies your right to get services outside the provider network.
  • Denies your request to dispute what you must pay for services or coverage.

An expedited (fast) appeal is when you ask your MCE to review their decision quickly because waiting 30 days could harm your life, health, or ability to function. If the MCE agrees with the request, they must resolve the appeal within 48 hours.

We can help you with appeals:

  • We educate you on the appeals process.
  • We listen to you.
  • We help you decide if you want to file a standard or expedited appeal.
  • We record your complaint and ask you to confirm the information is correct.
  • We file an appeal on your behalf if you ask us to.
  • We answer questions about an appeal you asked us to help with.

An external review is a review by a group outside your MCE. If you do not agree with the MCE's appeal decision, you can ask for an external review. An independent review organization (IRO) does the external review. The IRO reviews decisions when an MCE denied services or said a service wasn’t medically necessary, or claimed a service was experimental or investigational. You have 120 days from the date of the MCE's appeal decision to file for an external review. 

We can help you understand the external review process:

  • We educate you on the external review process.
  • We tell you to use the MCE grievance and appeals process before you ask for an external review.
  • We can help you ask for an external review.
  • We explain that the IRO must decide in 15 days (standard) or 72 hours (expedited).
  • We explain that the MCE must agree to the IRO’s decision.

A state fair hearing is a hearing you can ask for if you disagree with the MCE grievance or appeal decision. You can ask for this hearing after you use all MCE grievance and appeal options.

We can help you understand the state fair hearing process:

  • We educate you on the state fair hearing process.
  • We tell you to go use the MCE's grievance and appeals process before you ask for a state fair hearing.
  • We advise you to ask for a state fair hearing within 120 days of the grievance or appeal decision.
  • We explain that the state fair hearing process can run at the same time as an external review.
  • We educate and support you as you get ready for a state fair hearing.
  • We advise you to ask for an agency review within 10 days of the judge's decision if you are not happy with the state fair hearing decision.

Learn more about
MCE grievances and appeals for members who have Medicare

Anthem Blue Cross and Blue Shield

Humana Healthy Horizons

UnitedHealthcare Community Plan of Indiana

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The Indiana PathWays for Aging Member Support Services, operated by Maximus
To learn more about PathWays, go to in.gov/pathways

Contact us: 1-877-738-3511 | indianapathwaysmss@maximus.com

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