Complaints, Grievances and Appeals

If your complaint is about a service you or a provider feels you need but we will not cover, you can ask us to review your request again. This is called an appeal.

If your complaint is about something other than not receiving a service, this is called a grievance. Examples of grievances would be not being able to find a doctor, trouble getting an appointment or not being treated fairly by someone who works at MPC or at your doctor’s office.

If you have a complaint you can contact us at 1-800-953-8854 or TTY/TDD at 1-800-735-2258.

If your complaint is about something other than not receiving a service, this is called a grievance. Examples of grievances would be not being able to find a doctor, trouble getting an appointment or not being treated fairly by someone who works at MPC or at your doctor’s office.

If your grievance is:

  • About an urgent medical problem you are having, it will be solved within 24 hours.
  • About a medical problem but it is not urgent, it will be solved within five days.
  • Not about a medical problem, it will be solved within 30 days.

If you would like a copy of our official complaint procedure or if you need help filing a complaint, please call the MPC’s Member Services Department at 1‑800‑953‑8854.

If you want to file an appeal you have to file it within 90 days from the date that you receive the letter saying that we would not cover the service you wanted.

How to file an appeal

You can call us to file your appeal or you may also send your appeal in writing. We have a simple form you can use to file your appeal. Just call 1‑800‑953‑8854 to get one. We will mail or fax the appeal form to you and provide assistance if you need help completing it.

Once you complete the form, you should mail it to:

Maryland Physicians Care, MCO
Attn: Grievance and Appeals Unit
1201 Winterson Rd, 4th floor
Linthicum Heights, MD 21060

Your doctor can also file an appeal for you if you sign a form giving him or her permission. Other people can also help you file an appeal, like a family member or a lawyer.

When you file an appeal, be sure to let us know any new information that you have that will help us make our decision. We will send you a letter letting you know that we received your appeal within 5 business days. While your appeal is being reviewed, you can still send or deliver any additional information that you think will help us make our decision.

What happens during the review process

When reviewing your appeal we will:

  • Use doctors who know about the type of illness you have
  • Not use the same people who denied your request for a service
  • Make a decision about your appeal within 30 days

Appeals timeline

The appeal process may take up to 44 days if you ask for more time to submit information or we need to get additional information from other sources. We will send you a letter if we need additional information.

If your doctor or MPC feels that your appeal should be reviewed quickly due to the seriousness of your condition, you will receive a decision about your appeal within three business days.

If we do not feel that your appeal needs to be reviewed quickly, we will try to call you and send you a letter letting you know that your appeal will be reviewed within 30 days.

If your appeal is about a service that was already authorized and you were already receiving, you may be able to keep getting the service while we review your appeal. Contact us at 1‑800‑953‑8854 if you would like to keep getting services while your appeal is reviewed. If you do not win your appeal, you may have to pay for the services that you received while the appeal was being reviewed.

Appeals decisions

Once we complete our review, we will send you a letter letting you know our decision. If we decide that you should not receive the denied service, that letter will tell you how to file another appeal or ask for a State Fair Hearing.