Grievance and Appeals
Provider Complaint/Grievance and Appeal Process
Claim Complaints must follow the Dispute process and then the Complaint Process below. Medical necessity and authorization denial complaints are handled in the Appeal process below. Please note that claim payments are not appealable. These must be handled via the Claim Dispute and Complaint process. Claim Disputes may be mailed to:
Arkansas Total Care
Attn: Appeals Department
PO Box 25010
Little Rock, AR 72221
A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Arkansas Total Care’s policies, procedure, or any aspect of Arkansas Total Care’s functions. Arkansas Total Care logs and tracks all complaints/grievances whether received verbally or in writing. After a complete review of the complaint/grievance, Arkansas Total Care shall provide
Authorization and Coverage Appeals
Authorization and Coverage Appeals must follow the Appeal process below.
An Appeal is
Expedited appeals may be filed with Arkansas Total Care if the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding seventy-two (72) hours from the initial receipt of the appeal. Arkansas Total Care may extend this timeframe by up to an additional fourteen (14) calendar days if the member requests the extension or if Arkansas Total Care provides evidence satisfactory evidence that a delay in rendering the decision is in the member’s best interest.
Providers may also invoke any remedies as determined in the Participating Provider Agreement.
Member Complaint/Grievance and Appeal Process
To ensure that Arkansas Total Care members' rights are protected, all Arkansas Total Care members are entitled to a Complaint/Grievance and Appeals process. The procedures for filing a Complaint/Grievance or Appeal are outlined in the Arkansas Total Care member’s Summary of Benefits. You can find the Summer of Benefits on the Member Resources page. Additionally, information regarding the Complaint/Grievance and Appeal process can be found on our website at ArkansasTotalCare.com or by calling Arkansas Total Care at 1-866-282-6280 or TTY: 711.
If a member is displeased with any aspect of services rendered:
- The member should contact our Member Services department at 1-866-282-6280 or TTY: 711. The Member Services representative will assist the member.
- If the member continues to be dissatisfied, they may file a formal complaint/grievance. Again, our Member Services department is available to assist with this process. Information regarding this process can be found at ArkansasTotalCare.com.
- Depending on the nature of the complaint/grievance, the member will be offered the right to appeal our decision. At the conclusion of this formalized process, the member will receive written confirmation of the determination. Arkansas Total Care will complete the appeal process in the timeframes as specified in rules and regulation.
- The member or provider has the right to appeal to request a state fair hearing of Arkansas Total Care’s appeal decisions.
- A member may designate in writing to Arkansas Total Care that a provider is acting on behalf of the member regarding the complaint/grievance and appeal process.
The mailing address for non-claim related Member and Provider Complaints/Grievances and Appeals is:
Arkansas Total Care
P.O. Box 25010
Little Rock, Arkansas 72221