Complaints and Appeals

A grievance is an expression of dissatisfaction about any matter other than an Adverse Benefit Determination. Grievances may be received orally, in writing, or your My Magnolia Mobile App and may be submitted to Magnolia by you or your child’s authorized representative, including your child’s provider. A member may file a grievance either orally or in writing with Magnolia any time after the grievance has occurred.

Examples of a grievance:

•    Failure to respect your child’s rights

•    The quality of care or services provided

•    Aspects of interpersonal relationships such as rudeness of a provider or an employee

A complaint is an expression of dissatisfaction that is of less serious or formal nature that is resolved within one (1) calendar day of receipt. Complaints may be received orally or in writing and may be submitted to Magnolia by you or your child’s authorized representative, including your child’s provider. Complaints must be submitted to Magnolia within thirty (30) days of the date of the event causing dissatisfaction.  A grievance may be filed at any time.

Filing a grievance or complaint will not affect your child’s healthcare services. We want to know your concerns so we can improve our services.

To file a grievance or complaint, call Member Services at 1-866-912-6285, mail in your complaint, or use your MyMagnolia Mobile App.  Pharmacy complaints and grievances related to claims processed on or after July 1, 2024, will be handled by Gainwell Technologies (GWT). The GWT pharmacy call center number is 833-660-2402. Magnolia will provide reasonable assistance to members in filing a grievance or complaint.

You can also write a letter and mail or fax your grievance or complaint to Magnolia at 1-877-264-6519. Be sure to include:

•    Your child’s first and last name

•    Your child’s Member ID number

•    Your child’s address and telephone number

•    What you are unhappy with

•    What you would like to have happen

A grievance or complaint may be filed in writing or by mailing it to the address below or by faxing it to 1-877-264-6519. You can also call us at 1-866-912-6285 or file the grievance or complaint in person at:

Magnolia Health Grievance Coordinator

1020 Highland Colony Parkway, Suite 502

Ridgeland, MS 39157

If you file a grievance, either oral or written, the Grievance Coordinator will send you a letter within five (5) calendar days letting you know that we have received your child’s grievance and include the expected date of resolution.

If someone else is going to file a grievance or complaint for your child, we must have your written permission for that person to file your child’s grievance or complaint. You can call Member Services to receive a form or go to www.MagnoliaHealthPlan.com. This form gives your right to file a grievance or complaint to someone else. A provider acting for your child can file a grievance or complaint for your child with your written consent.

If you have any proof or information that supports your grievance, you may send it to us and we will add it to your child’s case. You may supply this information to Magnolia by including it with a letter, by sending us an email or a fax, or by bringing it to Magnolia in person. You may also request to receive copies of any documentation that Magnolia used to make the decision about your child’s grievance.

You can expect a resolution and a written response from Magnolia within thirty

(30) calendar days of receiving your grievance. Magnolia may extend by up to fourteen (14) calendar days if the member requests the extension, or if Magnolia determines that there is a need for additional information and the extension is in the member’s best interest. For any extension not requested by the member, Magnolia shall give the member written notice of the reason for the extension within two (2) calendar days of the decision to extend the timeframe.

If you disagree with Magnolia’s decision for an extension, you may file a grievance regarding the dissatisfaction.

There will be no retaliation against you or your child’s representative for filing a grievance or complaint with Magnolia.

An appeal is a request for Magnolia to review an Adverse Benefit Determination. You can request this review by phone or in writing.

An Adverse Benefit Determination occurs when Magnolia:

•    Denies or limits authorization of a service you want

•    Decreases, suspends, or ends care that your child is already getting

•    Denies all or part of payment for covered care and you may have to pay for it

•    Fails to provide services in a timely manner as defined by the state

•    Denies the right to request services outside the network (for residents in rural areas)

•    Denies a member’s request to dispute a financial liability, including cost sharing, copayment, premiums, deductibles, coinsurance, and other enrollee financial liabilities

You will know that Magnolia is taking an action because we will send you a letter. The letter is called an Adverse Benefit Determination Notice. If you do not agree with the action, you may request an appeal. You can request an appeal by phone or in writing.

•    The member (or the parent or guardian of a minor member)

•    Any person named by you (Authorized Representative)

•    A provider acting for your child (Authorized Representative)

You must give written permission if someone else (Authorized Representative) files an appeal for your child. Magnolia will include a form (Authorized Representative Form) in the Adverse Benefit Determination Notice. Contact Member Services at 1-866-912-6285 if you need help. We can assist you in filing an appeal. Pharmacy appeals related to prior authorizations decisioned on or after July 1, 2024, will be reviewed by GWT. The GWT pharmacy call center number is 1-800-884-3222.

An  appeal may be filed orally, in writing or by mailing it to the address below or by faxing it to 1-877-264-6519. You may file an appeal on your MyMagnolia Mobile App. You can also call us at 1-866-912-6285 or file the grievance or complaint in person at:

Magnolia Health Grievance Coordinator

1020 Highland Colony Parkway, Suite 502

Ridgeland, MS 39157

The Adverse Benefit Determination Notice will tell you about this process. You may file an appeal within sixty (60) calendar days of the date on the Adverse Benefit Determination Notice. Within ten (10) calendar days, Magnolia will send you a letter, letting you know your appeal was received and give you an expected date that the appeal will be resolved.

You may present evidence and examine the case file and other documents related to the appeal in person, as well as in writing. You may examine your child’s case file, including medical records and any other documents and records used during the appeals process. Copies will be given to you at no cost at your request.

Continuation of Benefits

If all of the following are met, you may ask to keep getting care (benefits) related to your appeal while we decide:

1.  You file an appeal of an Adverse Benefit Determination on or before ten (10) days from the date on the Adverse Benefit Determination letter or the date of the adverse action based on whichever date is later.

2.  The appeal involves the termination, suspension or reduction of a previously authorized course of treatment.

3.  The services were ordered by an authorized service provider.

4.  The time period covered by the original authorization has not expired.

5.  You request extension of the benefits.

If, at your request, Magnolia continues or reinstates your benefits while the appeal or Independent External Review is pending, the benefits must be continued until one of the following occurs:

•    You withdraw the appeal or request for an Independent External Review.

•    You fail to request an Independent External Review and continuation of benefits within 10 calendar days after Magnolia sends the notice of an adverse resolution to the enrollee’s appeal.

If the final decision is to uphold Magnolia’s Adverse Benefit Determination, Magnolia may recover the cost of services furnished to your child while the appeal and Independent External Review was pending. In other words, you may have to pay for this care if the decision is not in your child’s favor.

You may request to extend the time for more than sixty (60) calendar days to file an appeal. This request must be given in writing and tell why the request was not filed within the 60 days.

Magnolia will give you a written decision within thirty (30) calendar days from the date of your request. The decision will be made by a reviewer with the appropriate expertise. If more than thirty (30) days is needed to make a decision, we will send a letter to you. Magnolia may extend the thirty (30) calendar day timeframe by fourteen (14) calendar days if you request the extension, or Magnolia decides

that more information is needed, and will give you written notice of the extension within two (2) calendar days of the decision to extend the timeframe. If you disagree with Magnolia’s decision for an extension, you have the right to file a grievance regarding the dissatisfaction.

You or your child’s provider may want us to make a fast decision. You can ask for an expedited review if you or your child’s provider feel that your child’s health is at risk. If you feel this is needed, call our Clinical Appeals Coordinator. If an expedited appeal is made by phone, follow-up with a written, signed appeal is not required.

We will decide within 72 hours of receipt of the expedited appeal request. However, Magnolia may extend up to fourteen (14) calendar days if you request an extension, or if Magnolia determines that the extension is in your child’s best interest. You will also receive a letter telling the reason for the decision and what to do if you don’t like the decision. If you disagree with Magnolia’s decision for an extension, you have the right to file a grievance regarding the dissatisfaction.

Expedited appeals do not require a signed authorization form.

Magnolia will make reasonable efforts to provide and document verbal notice of an expedited appeal resolution.