A grievance is a complaint about a provider or the level of care or services you received. You should let us know right away if you have a poor experience.

You can file a grievance if you are unhappy with things like:

• The quality of care you received
• Long wait times for appointments
• How a doctor, staff member, or pharmacy treated you
• Trouble getting answers or reaching someone by phone

An appeal is a request asking Meridian to review and change a decision about your care or coverage. For example, we may not approve your provider’s request for a certain drug. You can make an appeal if you disagree with our decision.

The following list includes examples of when you might want to file an appeal:

• Not approving or paying for a service or item your provider asks for
• Stopping a service that was approved before
• Not giving you the service or items in a timely manner
• Not advising you of your right to choose your providers
• Not approving a service for you because the provider was not in our network

• You can file a grievance or appeal for yourself
• You can choose someone you trust to help you, like a family member, friend, or doctor
• Your provider may also file on your behalf

When you go to file a grievance, you’ll want to write when and where the incident took place, and what happened.

You can file a grievance in these ways:

• Call 866-606-3700 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. to speak with one of our representatives.
• If you or someone acting on your behalf wishes to file a grievance, please complete a Grievance Form (PDF) and mail or fax to:
  Meridian
  Attn: Grievance Department
  PO Box 10353
  Van Nuys, CA 91410-0353
  Fax: 833-669-1734

In the grievance letter, give us as much information as you can. For example, include the date and place the incident happened, the names of the people involved, and details about what happened. Be sure to include your name and your member ID number.

We will try to resolve your grievance quickly. If we cannot, we may contact you for more information.

You or your representative, such as a provider, family member, friend, or attorney, may file an appeal on your behalf with your written permission.

If someone acting on your behalf wishes to file an appeal, you must submit written permission to Meridian for an authorized representative to appeal on your behalf.

• Written permission can be provided by submitting an Authorized Representative Designation Form (PDF)

Standard Appeal Request: You or your authorized representatives have sixty (60) calendar days from the date of the Adverse Benefit Determination letter to file an appeal verbally or in writing. An Adverse Benefit Determination is a notice telling you that we denied, reduced, stopped, or did not approve or pay for a service or benefit you asked for.

If you want your services to stay the same while you appeal, you must say so when you appeal. You also must file your appeal no later than ten (10) calendar days from the date on our Adverse Benefit Determination letter.

Expedited Appeal Request: If you or your provider believes our standard timeframe of fifteen (15) business days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal by writing or calling us. If you write to us, please include your name, member ID number, the date of your Adverse Benefit Determination letter, information about your case, and why you are asking for the expedited appeal.

You can file standard and expedited appeals in these ways:

• Call the appropriate Member Services phone number below, depending on the type of appeal you are filing—medical or pharmacy. Hours are Monday through Friday, 8 a.m. to 5 p.m. to speak with one of our representatives.
• Mail or fax your written appeal request to the appropriate address listed below.

Please note behavioral health and pharmacy appeals are managed separately from other healthcare services appeals.

• Meridian fairly reviews your grievance or appeal
• We do not treat you differently for filing
• A decision is shared with you or your provider

Within three (3) business days of receiving an appeal, Meridian will confirm receipt in writing. We will make a decision about the appeal and notify you and your PCP, as well as any other providers involved in the appeal, in writing within 15 business days of receiving all required information. We will tell you if we need more information and how to give us such information in person or in writing.

Things to keep in mind during the appeal process:

• At any time, you can provide us with more information about your appeal, if needed
• You have the option to see your appeal file
• You have the option to be there when Meridian reviews your appeal

You can find more details in your Meridian Medicaid Member Handbook, which explains your rights and steps in full.

Meridian will let you know within twenty-four (24) hours if we need more information. Once all information is provided, we will call you within twenty-four (24) hours to inform you of our decision and will also send you and your authorized representative the Decision Notice.

After you receive the Meridian appeal Decision Notice in writing, you do not have to take any action, and your appeal file will be closed. However, if you disagree with the decision made on your appeal, you can take action by asking for a State Fair Hearing Appeal and/or asking for an external review of your appeal within thirty (30) calendar days of the date on the Decision Notice. You can choose to ask for both a State Fair Hearing Appeal and an external review, or you may choose to ask for only one of them.

You can find more details in your Meridian Medicaid Member Handbook.