During the COVID-19 Public Health Emergency (PHE), the Pennsylvania Department of Human Services (DHS) temporarily suspended the need for a Medicaid health insurer or plan to determine medical necessity (also called prior authorization) for children receiving shift care services like skilled nursing and home health aide. As a result, anyone who was getting shift care services when the pandemic began, or who was approved for services during the pandemic, could not have those services reduced or terminated while the PHE continued. However, DHS recently announced that the freeze on pediatric shift care services will lift on November 1, 2022.
PHLP previously provided resources about the importance of strong prior authorization packets when submitting requests for these services. Yet even with a strong prior authorization packet, participants may still be denied for the continuation of current services or denied new or additional services. If services are denied, individuals have the right to challenge that decision by filing an appeal. Below are the steps to file an appeal if shift care services are denied or reduced when the freeze lifts.
Step 1: Ask for a Grievance
If your child is in a Medicaid managed care plan, your first step is to ask for a grievance through your health plan. If your child is in Fee for Service, and has an Access Card, go to Step 3 (below) to learn how to ask for a fair hearing.
A grievance is a review of the health plan’s decision by a panel of at least three people, including a doctor from the managed care plan. You have the right to participate in the grievance either in person, through videoconference, or by phone. You also can bring representation, and have your doctor or others participate. You also have the right to submit new and additional documentation to support the medical necessity of the service. Ask your doctor to participate by attending the review by phone or in person, and/or by writing a letter that explains why the service is medically necessary. The grievance panel must hold the meeting and give you a decision in writing within 30 days from when you asked for the grievance.
If waiting 30 days would harm your child’s health, you can request an “expedited” grievance. An expedited grievance can be requested by having your doctor submit a letter that says waiting 30 days will harm your child’s health and they are requesting the grievance be expedited. Along with any other relevant information. For an “expedited” grievance, the panel must hold your meeting and provide you with a decision within 72 hours of your request.
To ask for a grievance, call your health plan’s member services line or complete the grievance request form that came with your denial letter. If you complete the form, send it by certified mail or fax and keep a receipt.
If your insurance plan tries to reduce any services your child is currently receiving, request a grievance within 10 days of the date on the written notice to keep those services in place while the appeal is being decided. You have 60 days from the date on the denial letter to file a grievance.
The grievance decision can result in one of three decisions:
1) Overturned – Service hours are approved by your health plan as requested by the provider;
2) Approved as Other than Requested – Approved some hours, but not fully as requested by the provider. For example, you requested 40 hours per week, and the health plan instead approved 20 hours per week, or;
3) Upheld – The health plan is upholding their original decision and not approving services as requested.
If the grievance decision is anything other than overturned, you can move forward with the next phases of appeal. If this is a new service, you can also use any of the hours approved while you await the external review and/or fair hearing decisions.
Step 2: Ask for an External Review
If you do not agree with the grievance decision, you have the right to ask for an external review. An external review is a review of the record by an independent doctor chosen by the PA Department of Insurance. The external reviewer must give you a decision within 60 days of your request. Call your health plan’s member services phone number to ask for an external review. You have 15 days from the date on the grievance decision to ask for an external review. Ask within 10 days of the grievance decision if you want benefits to continue during the external review process.
This is a paper review, and there is no meeting. You can submit new and updated information for review at the external review level. You want to submit the documentation to the external reviewer itself, as well as the health plan.
Step 3: Ask for a Fair Hearing
If you do not agree with the health plan’s grievance decision, you have the right to a fair hearing. A fair hearing is a meeting where the health plan must explain its decision to an administrative law judge. You must take part in the hearing either in person or by phone. At the hearing, you have the right to submit evidence and to explain your position to the judge. Your doctor or others can also take part. To ask for a fair hearing, complete the form that came with your grievance decision. Include the grievance decision with your form. Send it by certified mail or fax and keep a receipt. You have 120 days from the date on the grievance decision to ask for a fair hearing. Once you request the fair hearing, it should be scheduled, and you should receive a written decision within approximately 90 days. Ask for a fair hearing within 10 days of the date on the grievance decision if you want the services you are already getting to continue until you get a fair hearing decision.
If waiting months for a decision would harm your child's health, you may request an “expedited fair hearing.” An expedited fair hearing can be requested by submitting a letter to the bureau of hearings and appeals with your request form that says waiting 90 days will harm your child’s health and/or jeopardize their safety and they are requesting the grievance be expedited. Along with any other relevant information. In an “expedited” fair hearing, the judge will hold the hearing and give you a decision within three business days of your request.
You should ask for an external review and a fair hearing at the same time, especially if you want to continue the services you are currently receiving. If either appeal is decided in your favor, the plan must approve the service.
You do not have ask for an expedited grievance or fair hearing if you are continuing to receive your services throughout the appeal process.
If you receive a denial notice, free legal help is available through PHLP’s Helpline at 1-800-247-3258. You can also look at our appeals factsheet for easy reference.