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Filing an Appeal

Do you disagree with a decision about your benefit? 
You may be able to file an appeal. The appeal process is different based on the type of benefit issue you have:

If your care is denied, your contractor will send you a letter with details about how to file your appeal.

Who can file an appeal?

  • You, the beneficiary
  • Your custodial parent or guardian
  • A person appointed by you in writing
  • An attorney filing on your behalf
  • Non-network, participating providers

Is there a provider or other party that is filing your appeal?

  • You must complete an Authorization to Disclose Information.
  • We can’t process your appeal without this form.
  • Network providers aren’t appropriate appealing parties, but you can appoint them in writing.
  • Non-participating providers can’t file an appeal for you.

What types of decisions can you appeal?

You can file an appeal if:

  • We deny payment for services or supplies you received
  • We deny prior authorization for requested services or supplies
  • We stop payment for services or supplies that were previously authorized
  • We deny a provider’s request for approval as an authorized provider

What types of decisions can’t you appeal?

You can’t appeal the following:

  • Allowable charges
  • Eligibility
  • Denial of services from an unauthorized provider
  • Denial of treatment plan when you select an alternative treatment plan
  • Refusal by your primary care manager to provide services 
  • Refusal by your primary care manager to refer you to a specialist
  • Point of service issues, except for services related to an emergency

For these types of decisions, you can file a grievance.

Key Things to Remember

You should:

  • Meet all required deadlines
  • Send your appeals in writing with signatures
  • Include copies of all supporting documents
  • Keep copies of everything for your records

Last Updated 5/20/2015

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