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