APPEALING DETERMINATIONS AND DECISIONS
Depending on a person's insurance, a person likely has the right to appeal various decisions made by their insurer. The process for appealing differs depending on the decision made and depending on the type of insurance. Here are some common concepts that apply to Medical Assistance and other healthcare programs in PA.
Appealing Eligibility Determinations from Publicly Funded Health Care Programs
When a person applies for health care coverage through a state or federally funded health care program such as Medical Assistance, CHIP, adultBasic, PACE/PACENET, or Medicare, there are rules that apply to the decision making process. There are set timeframes and procedures for when applications must be reviewed, when written decisions must be sent, and what processes must be followed for appealing a decision denying someone admission to a program. Similar protections are in place for health care program decisions on terminations or changes in eligibility.
For more information about the eligibility appeals process for Medical Assistance, see below. For more information about the CHIP, adultBasic, PACE/PACENET, or Medicare, call the Pennsylvania Health Law Project at (800)274-3258.
MEDICAL ASSISTANCE ELIGIBILITY APPEALS
Fair Hearing Requests - Appealing a Denial, Termination, or Change in Eligibility
When a person applies for Medical Assistance and is denied or approved for a lesser benefit, the person may file an appeal. Similarly, when a person has been on Medical Assistance and is notified that he/she is having their eligibility terminated or changed, the person may file an appeal. This appeal is through the Medical Assistance Bureau of Hearings and Appeals and is referred to as filing for a FAIR HEARING.
In order for the appeal to be heard the written request must be postmarked on or before 30 calendar days following the date the notice is mailed or hand-delivered to the applicant or recipient. After this date, the Office of Hearings and Appeals reserves the right, by regulation, to dismiss the appeal without a hearing. If you need help filing your appeal, call the Pennsylvania Health Law Project at (800)274-3258. If you are currently receiving Medical Assistance and your appeal is post-marked on or before the tenth calendar day following the date the notice is mailed or hand-delivered to you, you will continue to receive services pending the outcome of the hearing. If however, your appeal is postmarked after this date, service will be discontinued or reduced on the effective date.
Request for Reconsideration and Appealing to Commonwealth Court
If dissatisfied with the outcome of the hearing, the person's recourse is to request reconsideration of the decision of the hearing officer. A written request for reconsideration must be filed with the Secretary of the Department of Public Welfare within 15 calendar days from the date of the hearing officer's decision. A request for reconsideration will stay the action proposed in the decision of the hearing officer. After reviewing the factors considered by the hearing officer and the request for reconsideration, the Secretary will respond in writing to the request.
A person or representative may appeal the decision of the Secretary of the Department of Public Welfare to the Commonwealth Court within 30 days from the date that the Secretary responds to the request for reconsideration.
CHIP ELIGIBILITY APPEALS
Request for Review – Appealing a Denial, Termination or Change in Coverage
When a child is found ineligible for CHIP, an impartial eligibility review may be requested. The contractor is required to send a notice informing the parent or guardian the reason for ineligibility, the right to request an impartial review and how to file a request for impartial review.
A request for impartial review must be filed in written or printed form (e.g., letter, email, fax) and be postmarked or received within 30 calendar days of the date of the notice. The request should contain the reason for the review and be signed by the parent or guardian. If a parent or guardian files an oral request for review, they must be informed by the CHIP contractor that the request must be reduced to writing within 3 working days of the oral request. The date of the oral request will be considered the date of the filing; however if no written request is received, the review interview will not be held.
A review officer of the Pennsylvania Insurance Department will complete the requested review. An interview will be conducted with you and a representative of the insurance contractor for CHIP. You may submit information to the review officer that explains why you think that the decision that was made was not correct. You may choose to have someone act as your representative.
If you request a review, you will receive more detailed information from the Pennsylvania Insurance Department, including time and date that the interview will be conducted. You may request a face-to-face interview. You have the right to review records made by the contractor regarding the eligibility determination and the right to receive a copy of relevant portions of the CHIP Procedures Manual and State and Federal law upon which the decision of ineligibility was based.
If a child is found ineligible for CHIP renewal or the coverage is changed from Free CHIP to Subsidized CHIP, a notice must be sent to the parent or guardian at least 30 calendar days prior to termination or change of coverage. A written request for review must be received by the Pennsylvania Insurance Department within 30 days from the notice of ineligibility; enrollment in CHIP, including all benefits and services, will continue pending the outcome of an eligibility review.
Request for Reconsideration and Appealing to Commonwealth Court
A parent, guardian or representative may request reconsideration of the review officer if they are dissatisfied with the outcome of the review. A written request for reconsideration must be filed with the Insurance Commissioner within 15 calendar days from the date of the review officer's decision. A request for reconsideration will stay the action proposed in the decsion of the review officer. After reviewing the factors considered by the review officer and the request for reconsideration, the Insurance Commissioner will respond in writing to the request.
A parent, guardian or representative may appeal the decision of the Pennsylvania Insurance Department to the Common wealth Court within 30 days from the date that the Insurance Commisioner responds to the request for reconsideration.
adultBasic ELIGIBILITY APPEALS
Request for Review – Appealing a Denial or Termination
When an applicant is denied adultBasic eligibility or an enrollee's coverage is to terminated, the applicant or enrollee may request an impartial eligibility review within 30 days of the date of the notice of ineligibility or termination. A copy of the procedures on which the eligibility decision was based can also be requested. If a person requests help in filing a request for review, assistance should be provided promptly. The adultBasic contractor is required to send a notice informing the applicant or enrollee the reason for ineligibility, the right to request an impartial review and how to file a request for impartial review.
A request for impartial review must be filed in written or printed form (e.g., letter, email, fax) and be postmarked or received within 30 calendar days of the date of the notice. The request should contain the reason for the review and be signed by the applicant or enrollee. If an oral request for review is made, the adultBasic contractor must inform the applicant or enrollee that the request must be reduced to writing within 3 working days of the oral request. The date of the oral request will be considered the date of the filing; however if no written request is received, the review interview will not be held.
If you request a review, you will receive more detailed information from the Pennsylvania Insurance Department, including time and date that the interview will be conducted. You may request a face-to-face interview. You have the right to review records made by the contractor regarding the eligibility determination and the right to receive a copy of relevant portions of the Procedures Manual and State law upon which the decision of ineligibility was based.
A review officer from the Pennsylvania Insurance Department will complete the requested review. An interview will be conducted with you and a representative of the insurance contractor for adultBasic. You may submit information to the review officer that explains why you think that the decision that was made was not correct. You may choose to have someone act as your representative. The review officer will consider the eligibility factors, the documents provided and the relevant eligibility requirements.
If an enrollee is found ineligible for adultBasic renewal, coverage should be continued uninterrupted pending the outcome of eligibility review if the enrollee elects to continue paying the monthly premium until the review process is completed. If the enrollee elects not to pay the premium, coverage will not continue.
Request for Reconsideration and Appealing to Commonwealth Court
If dissatisfied with the outcome of the review, the person's recourse is to request reconsideration of the decision of the review officer. A written request for reconsideration must be filed with the Insurance Commissioner within 15 calendar days from the date of the review officer's decision. A request for reconsideration will stay the action proposed in the decision of the review officer. After reviewing the factors considered by the review officer and the request for reconsideration, the Insurance Commissioner will respond in writing to the request.
A person or representative may appeal the decision of the Pennsylvania Insurance Commissioner to the Commonwealth Court within 30 days from the date that the Insurance Commissioner responds to the request for reconsideration.
PACE/PACENET ELIGIBILITY APPEALS
Contact PACE for assistance at 1-800-225-7223 or email PACEcares@fhsc.com . Click here for more details
MEDICARE ELIGIBILITY APPEALS
The Social Security Administration reviews eligibility determinations through it appeals mechanism. See the page describing the eligiblity appeals process of the Social Security Administration for more information for more information the eligibility appeals process of the Social Security Administration.
PRIVATE HEALTH CARE COMPANY ELIGIBILITY APPEALS
Decisions to refuse coverage will be depend on the particular insurance policy, the insurance company, and the applicant or enrollee. Contact the Pennsylvania Insurance Department at (877) 881-6388 for guidelines.
Appealing Coverage Decisions - Denials, Terminations, or Reductions of Health Care Coverage
When a person is enrolled and receiving health care coverage through a state or federally funded health care program such as Medical Assistance, CHIP, adultBasic, PACE/PACENET, or Medicare, there are rules that apply to the decisions made with respect to health care benefits and services. If your Medical Assistance Healthchoices or Fee-for-Service plan denies a request you make or a recommendation your doctor makes, or does something else you disagree with, you have the right to file a grievance or a complaint. Grievances are appeals of decisions your health plan made fully or partially denying a requested service. It usually asks for a reconsideration of that decision. Complaints are formal complaints you file against your health plan, requesting they rectify the problem. It may be a dispute or objection regarding a participating provider, or about coverage, operations or management policies of the plan. There are set timeframes and procedures for when denials in coverage must be reviewed, when written decisions must be sent, and what processes must be followed for appealing a decision denying a service or benefit. Areas of complaints and grievances include: out-of-network service, payment issues, pharmacy/formulary, provider complaints, quality, referral/prior authorization, etc.
For more information about the appeals process for Medical Assistance, see below. For more information about the CHIP, adultBasic, PACE/PACENET, or Medicare, call the Pennsylvania Health Law Project at (800)274-3258.
MEDICAL ASSISTANCE BENEFITS APPEALS
Physical Health Disputes
If your Medical Assistance HealthChoices or Fee-for-Service plan denies you a service prescribed by one of your healthcare providers, approves a lesser benefit, or does something else you disagree with, you have the right to appeal the decision. There are three levels of the grievance process plus a Fair Hearing. If you have all ready been receiving the service or benefit, appealing within 10 days will usually keep it in place as a continuing benefit throughout the appeals process.
In Fee-for-Service, your appeal may be filed as a Request for Fair Hearing. In HealthChoices, your appeal may be filed as a Request for Fair Hearing, a grievance or a complaint, depending on the nature of the decision. For more information on appealing denials, terminations, or reductions of coverage/benefits, see our publication "What If I Disagree With My MA Health Plan" or call us at (800)274-3258.
Please note that each process has critical timeframes that must be followed. Failing to appeal a decision within the allotted timeframes may result in being unable to appeal. The most important timeframe is for appealing a decision that would terminate or reduce benefits that are already being received. These grievances and fair hearing requests must be mailed within 10 calendar days of the date of the decision in order for you to continue to get benefits during the appeal process.
For other critical timeframes, see our publication "What If I Disagree With My MA Health Plan" or call us at (800)274-3258.
Filing a grievance is not difficult, but it does require preparing and gathering a few items, including a grievance letter, letter(s) of support from a doctor(s), and possibly medical records. For a guide to writing a grievance letter to a health plan, see our brochure “Writing a Grievance Letter.” For a sample grievance letter, see “Sample Grievance Letter.” Medical necessity is usually a key issue. Use the appropriate definition of medical necessity, which differs if you are in a fee-for-service or managed care plan. For a helpful outline on how a doctor should write a letter of medical necessity, see “Letter of Medical Necessity Outline.” For information on requesting medical records see our flyer on requesting medical records and a sample medical records request letter. If these publications are unavailable or you require further information or representation, please call us at (800)274-3258.
Behavioral Health Disputes
If your Behavioral Health Managed Care Organization or Fee-for-Service plan denies you a service prescribed by one of your behavioral health providers, approves a lesser benefit, or does something else you disagree with, you have the right to appeal the decision. The appeals process is similar to Physical Health disputes, except some of the timeframes may change. For more information, call the Pennsylvania Health Law Project at (800)274-3258.
CHIP BENEFITS APPEALS
The private insurance company that has contracted with CHIP must follow the complaint and grievance procedures in Act 68 of 1999. Act 68 is administered jointly by the Department of Health and the Department of Insurance. Click to see the Department of Health regulations of Act 68 or the Department of Insurance regulations for Act 68.
Other private insurers may be governed by federal laws such as ERISA or only by contract provisions. For more information, contact the Pennsylvania Insurance Department. Contact Member Services of you disagree with a decision.
adultBasic BENEFITS APPEALS
The private insurance company that has contracted with CHIP must follow the complaint and grievance procedures in Act 68 of 1999. Act 68 is administered jointly by the Department of Health and the Department of Insurance. Click to see the Department of Health regulations of Act 68 or the Department of Insurance regulations for Act 68.
Other private insurers may be governed by federal laws such as ERISA or only by contract provisions. For more information, contact the Pennsylvania Insurance Department. Contact Member Services if you disagree with a decision.
MEDICARE BENEFITS APPEALS
See http://www.medicare.gov/publications/pubs/nonpdf/appeals.asp for more information about the Medicare Appeals and Grievances.
PRIVATE HEALTH INSURANCE BENEFITS APPEALS
Managed Care Organizations must follow the complaint and grievance procedures in Act 68 of 1999. Act 68 is administered jointly by the Department of Health and the Department of Insurance. Click to see the Department of Health regulations of Act 68 or the Department of Insurance regulations for Act 68.
Other private insurers may be governed by federal laws such as ERISA or only by contract provisions. For more information, contact the Pennsylvania Insurance Department.
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