If you are upset about the care you got, how someone treated you, or not having your rights respected, you can send a Complaint (also called a Grievance) to Magellan. You can also send a Complaint if you are upset about Magellan extending time to make a pre-authorization decision. You can file a Complaint at any time. You can file a complaint orally or in writing.

Examples of Complaints:

• You feel that you did not receive good service from your provider.
• You feel that you were not treated with respect or dignity.
• You feel that you are not getting the services you need from Magellan or the IDHW.

We will not tell anyone about your Complaint without your permission, unless we are required to by law, or unless another person or a provider is involved in your Complaint. If you file a Complaint, Magellan will not withhold care. You will still get the care that you need. You may ask for copies of your Complaint at any time.

You can file a Complaint with Magellan at any time.  Your provider, or another person you give permission to, can also file a Complaint on your behalf. You have the right to ask Magellan for help when filing your Complaint. 

When you file a Complaint, please include the following information:

1. Your first and last name
2. Your street address
3. Your city, state and ZIP code
4. Your telephone number
5. A description of your Complaint with any information that helps Magellan understand the issue

If your complaint is about YES services, you do not have to provide your name, address or any information about yourself or your youth. You can file a complaint anonymously.

You can file your Complaint in one of these three (3) ways:

1. Call Magellan at 1-855-202-0973 (TTY 711) between 8:00 a.m. and 6:00 p.m. Mountain Time.
   • A member services representative will help you submit the Complaint.
   • If you do not speak English, an interpreter will help you.
   • If member services cannot resolve your Complaint, it will be sent to the Complaint team.
2. Fax your Complaint to Magellan at 1-888-656-9795. (Click here to find the form on the Member Handbooks and Forms page)
3. Mail your Complaint to: (Click here to find the form on the Member Handbooks and Forms page)

         Magellan Healthcare, Inc.
         Attn: Idaho Quality Department
         PO Box 2188
         Maryland Heights, MO 63043

We will send you a letter in the mail within five (5) business days of receiving your Complaint. The letter will tell you we received your Complaint and are working on it. If we need more information, we may need to call you. We will work to resolve your Complaint within ten (10) business days from the date we received your Complaint. Some Complaints may need a more in-depth investigation. If we can’t resolve your Complaint within ten (10) business days, we will tell you.

Once we resolve your Complaint, we will send you a letter. It will explain:

• The answer to your Complaint
• The information we used to answer your Complaint
• What we did to answer your Complaint

The letter will also state we have finished working on your Complaint.

Appeals are related to your benefits. Magellan wants you to have the care you need. You have the right to disagree with any of our decisions or actions that affect your healthcare. You may file what is called an Appeal when you are unhappy with a decision Magellan made about your benefits. An Appeal is a request that Magellan review an Adverse Benefit Determination (ABD). If Magellan makes an ABD, we send you and your provider a letter. This is called an ABD Notice.

You may file an Appeal when:

• Magellan denied or limited a service that you or your provider requested (level of service, medical necessity, appropriateness, setting, or effectiveness of covered benefit).
• Magellan reduced or suspended a service that had already been pre-authorized.
• Magellan did not pay your provider for a service.
• Magellan did not provide timely service.
• Magellan did not respond quickly enough to a grievance or appeal.
• Magellan denied a member’s request to get care outside of the network.
• Magellan denied a request to dispute financial liability.

You, or someone you trust and give permission to, can ask for a free copy of the criteria, guidelines, or any other information Magellan used to make the decision by calling 1-855-202-0973 (TTY 711).

If you want to submit an Appeal, you must do so within sixty (60) calendar days of the date of the ABD Notice. You have the right to ask Magellan for help with the Appeal. You, your provider, or someone you give permission to, can file an Appeal over the phone or in writing.

Continuation of Benefits and Services
If you are getting services or benefits now and you appeal before the date they will end or within ten (10) calendar days from the date the ABD notice was mailed, then you may continue receiving the benefits and services until Magellan makes a final decision. This does not apply if a provider appeals. If the decision does not change, then Magellan may try to recover the cost of any extra services provided. 

There are two kinds of Appeals: Standard or Expedited (fast)

Standard Appeal
The standard appeal process requires Magellan to issue a decision within thirty (30) calendar days from the date the appeal is received. Magellan may request more information and will let you know if more time is needed.

Expedited (fast) Appeal
You should request an expedited (fast) Appeal if waiting thirty (30) calendar days for a decision could:

• Jeopardize your or your child’s life or health, or
• Jeopardize your or your child’s ability to attain, maintain or regain maximum function

You can ask for an expedited Appeal for yourself or your child. If you need an expedited Appeal, explain why, and if possible, ask your provider to send a letter explaining why. If you have questions about an expedited Appeal, contact Magellan. Magellan will determine if you meet the criteria for an expedited Appeal and tell you our decision within 72 hours. We will contact you if more time is needed.

If Magellan determines an expedited appeal is not necessary, the appeal request will be conducted as a standard appeal review timeline of thirty (30) days.

Whether you submit a standard or expedited Appeal, Magellan will not tell anyone about it without your permission, unless we are required to by law, or unless another person or a provider is involved in your Appeal. You will not be penalized for filing an Appeal. You will still get the care you need. Magellan is not allowed to stop your care if you file an Appeal. You may ask for copies of your Appeal at any time.

Your Appeal must include the following information:

1. Your personal information:
   • First and last name
   • Your member ID number
   • Your date of birth
   • Your street address
   • Your city, state and ZIP code
   • Your telephone number
2. Information that you think supports your Appeal
3. Why you disagree with Magellan’s decision
4. The name of any person filing an Appeal for you, along with your signature that gives that person permission to do so

You can file your Appeal in one of these three (3) ways:

1. Call Magellan at 1-855-202-0973 (TTY 711) between 8:00 a.m. and 6:00 p.m. Mountain Time.
   • A member services representative will help you submit the Appeal.
   • If you do not speak English, an interpreter will help you.
2. Fax your Appeal to Magellan at 1-888-656-9795 (Click here to find the form on the Member Handbooks and Forms page)
3. Mail your appeal to Magellan (Click here to find the form on the Member Handbooks and Forms page):

         Magellan Healthcare, Inc.
         Attn: Idaho Quality Department
         PO Box 2188
         Maryland Heights, MO 63043

When we receive your Appeal, we will tell you and your provider that we received it by sending you a letter in the mail within five (5) business days.

We will tell you and your provider the Appeal decision within thirty (30) calendar days of when we received your Appeal. This is the standard review timeline. We will send both of you a letter in the mail.

If we need more time to review your Appeal, we can ask the IDHW for fourteen (14) more calendar days. If we need more time, we will tell you about this request by phone and letter within two (2) calendar days of contacting the IDHW. If the IDHW agrees with our request, we will tell you in writing.

If you disagree with the outcome of the appeal to Magellan or Magellan misses their deadline to make a decision about your Appeal, you have the right to submit an appeal to IDHW and ask for a State Fair Hearing. You can only ask for a State Fair Hearing once you have finished the Appeal process with Magellan. You can find the State Fair Hearing request form in the Member Handbooks and Forms section of this website.

You can ask for a Fair Hearing if:

• You have completed the Appeal process with Magellan and you are still dissatisfied with our decision on your Appeal; or
• You did not receive a Notice of Appeal Resolution Letter within 72 hours from receipt of Appeal for Expedited (fast) Appeal; or
• You did not receive a Notice of Appeal Resolution Letter within 30 calendar days from receipt of Appeal for Standard Appeal.

You have 120 days from the date of the Appeal decision letter to ask for a State Fair Hearing from IDHW. The Appeal decision letter will tell you how you can keep getting the services while you go through the appeal and state fair hearing process with IDHW. You may have to pay for any services you kept getting if the outcome of the State Fair Hearing agrees Magellan made the right decision. If you want to keep getting these services, you must request the State Fair Hearing within ten (10) days of the date on Magellan’s Appeal decision letter. 

You may send additional information with your Fair Hearing request. Additional information is not a requirement. You do not have to wait to have the records to request a Fair Hearing.

Examples of additional information are medical records, doctor’s notes, or financial records that support the reasons for the Fair Hearing request. Keep your own copies of any documents you send. 

You, your provider, or a person you trust can send the IDHW appeal and State Fair Hearing request. The Office of the Attorney General will hold the hearing. State Fair Hearings are always over the phone. During the hearing, IDHW will be asked to explain why Magellan’s decision was correct. You will be asked to tell the state why you disagree with Magellan’s Appeal decision. Your provider or a person you trust can help you and attend the hearing. 

After the hearing, the hearing officer will give you, your provider, and IDHW a final decision within thirty (30) days from the date of the hearing. If the decision is that Magellan’s decision was correct, you may have to pay for the services if you continued to get during the appeal and State Fair Hearing process. 

You, your provider, or someone you trust may ask for a State Fair Hearing by sending an appeal to the IDHW. You can find the State Fair Hearing request form in the Member Handbooks and Forms section of this website. There are four (4) ways to ask for a State Fair Hearing:

1. Call the IDHW at (208) 334-5747 (TTY 711) (local) or 1-877-200-5441 (TTY 711) (toll free) and tell the person that you want a State Fair Hearing
2. Fax your request to (208) 364-1811
3. Email your request to MedicaidAppeals@dhw.idaho.gov
4. Mail your request to:

            Idaho Department of Health and Welfare
            PO Box 83720
            Boise, ID 83720-0009