Complaints and Appeals

If you are unhappy with anything about Buckeye or its providers, you should contact us as soon as possible. This includes if you do not agree with a decision we have made. You, or someone you want to speak for you, can contact us. If you want someone to speak for you, you will need to let us know this. Buckeye wants you to contact us so that we can help you. To contact us you can:

• Call the Member Services department at 1-866-246-4358 (TDD/TTY: 1-800-750-0750)
• Fill out the form in your member handbook
• Call the Member Services department to request they mail you a form
• Visit our website at www.buckeyehealthplan.com
• You have the right to appoint a representative to file an appeal or grievance on your behalf. If you desire to exercise this right you will be required to complete and submit an Appointment of Representative Form (PDF) with your request.
• Write a letter telling us what you are unhappy about. Be sure to put your first and last name, the number from the front of your Buckeye member ID card, and your address and telephone number in the letter so that we can contact you, if needed. You should also send any information that helps explain your problem.

Send any forms/letters to:

Buckeye Health Plan
Appeals/Grievance Coordinator
4349 Easton Way, Suite 120
Columbus, OH 43219

Buckeye will send you something in writing if we make a decision to:

• deny a request to cover a service for you
• reduce, suspend or stop services before you receive all of the services that were approved
• deny payment for a service you received that is not covered by Buckeye

We will also send something in writing if, by the date we should have, we did not:

• make a decision on whether to okay a request to cover a service for you
• give you an answer to something you told us you were unhappy about

If you do not agree with the decision/action listed in the letter, and you contact us within 60 calendar days to ask that we change our decision/action, this is called an appeal. The 60 calendar day period begins on the day after the mailing date on the letter. Unless we tell you a different date, we will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us.

If we have made a decision to reduce, suspend or stop services befor you receive all of the services that were approved, your letter will tell you how you can keep receiving the services if you choose and when you may have to pay for the services.

Grievances

If you contact us because you are unhappy with something about Buckeye or one of our providers, this is called a grievance. Buckeye will give you an answer to your grievance by phone (or by mail if we can’t reach you by phone) within the following time frames:

• 2 working days for grievances about not being able to get medical care
• 30 calendar days for all other grievances except grievances that are about getting a bill for care you have received
• 60 calendar days for grievances about getting a bill for care you have received

You also have the right at anytime to file a complaint by contacting the:

Ohio Department of Medicaid
Bureau of Managed Care
P.O. Box 182709
Columbus, OH 43218-2709
1-800-605-3040 or 1-800-324-8680
TTY: 1-800-292-3572

Ohio Department of Insurance
50 W. Town Street, 3rd Floor, Suite 300
Columbus, OH 43215
1-800-686-1526

State Hearings

Buckeye will notify you of your right to request a state hearing when:

• a decision is made to deny services
• a decision is made to reduce, suspend, or stop services before all of the approved services are received
• a provider is billing you because Buckeye has denied payment of the service
• a decision is made to propose enrollment or continue enrollment in the Buckeye Controlled Substances and Member Management (CSMM) program
• a decision is made to deny your request to change your Buckeye Controlled Substances and Member Management (CSMM) provider

At the time Buckeye makes the decision, or is aware that the provider is billing you for payment, we will mail you a state hearing form. If you want a state hearing, you must request a hearing within 90 calendar days. The 90 calendar day period begins on the day after the mailing date on the hearing form. If we have made a decision to reduce, suspend, or stop services before all of the approved services are received and you request the hearing within 15 calendar days from the mailing date on the form, we will not take the action until all approved services are received or until the hearing is decided, whichever date comes first. You may have to pay for services you receive after the proposed date to reduce, suspend, or stop services if the hearing officer agrees with our decision.

State hearing decisions are usually issued no later than 70 calendar days after the request is received. However, if the MCP or Bureau of State Hearings decides that the health condition meets the criteria for an expedited decision, the decision will be issued as quickly as needed, but no later than 3 working days after the request is received. Expedited decisions are for situations when making the decision within the standard time frame could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function.

To request a hearing you can sign and return the state hearing form to the address or fax number listed on the form, call the Bureau of State Hearings at 1-866-635-3748, or submit your request via e-mail at bsh@jfs.ohio.gov. A state hearing is a meeting with you, someone from the County Department of Job and Family Services, someone from Buckeye and a hearing officer from the Ohio Department of Job and Family Services. Buckeye will explain why we made our decision and you will tell why you think we made the wrong decision. The hearing officer will listen and then decide who is right based upon the information given and whether we followed the rules. If you want information on free legal services but don’t know the number of your local legal aid office, you can call the Ohio State Legal Services Association at 1-800-589-5888, for the local number.