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Grievance and Appeals

Complaint Process

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

Complaint/Grievance

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 a written notice to the provider within thirty (30) calendar days of the received date of Arkansas Total Care’s decision. If the complaint/grievance is related to claims payment, the provider must follow the process for claim reconsideration or claim dispute as noted in the Claims section of this Provider Manual prior to filing a complaint.

Authorization and Coverage Appeals

Authorization and Coverage Appeals must follow the Appeal process below.
An Appeal is the mechanism which gives members and providers the right to appeal actions of Arkansas Total Care such as a prior authorization denial, or if the provider is aggrieved by any rule, policy, procedure, or decision made by Arkansas Total Care. A provider has sixty (60) calendar days from Arkansas Total Care’s notice of action to file the appeal. Arkansas Total Care shall acknowledge receipt of each appeal within five (5) business days after receiving an appeal. Arkansas Total Care shall resolve each appeal and provide written notice of the appeal resolution as expeditiously as the member’s health condition requires but shall not exceed thirty (30) calendar days from the date Arkansas Total Care receives the appeal. Arkansas Total Care may extend the timeframe for resolution of the appeal up to fourteen (14) calendar days if the member requests the extension or Arkansas Total Care demonstrates that there is a need for additional information and how the delay is in the member’s best interest. For any extension not requested by the member, Arkansas Total Care shall provide written notice to the member for the delay.

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, 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 time frame 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 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 Summary 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. A 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 the rules and regulations.
  • 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.

Mailing Address

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