What is an appeal?

Medicaid members have a right to appeal Plan decisions to the Plan. When members do not agree with Plan decisions on an appeal, they can ask the State Medicaid agency for a State Fair Hearing.

When you ask for an appeal, your Plan has 30 days to give you an answer. You can ask questions and give any updates (including new medical documents from your providers) that you think will help the Plan approve your request. You may do that in person, in writing or by phone.

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider or a lawyer to help you. You can call Member Services at 1-855-375-8811 (TTY 1-866-209-6421) if you need help with your appeal request. It’s easy to ask for an appeal by using one of the options below:

  • Mail: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the addresses listed on the form. We must receive your form no later than 60 days after the date on this notice.
  • Fax: Fill out, sign and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax numbers listed on the form.
  • By phone: Call 1-855-375-8811 (TTY 1-866-209-6421) and ask for an appeal. You will get help with your form during this call. You will still need to send us your Appeal Request Form after you call. There are instructions on the form that tell you what to do.

When you appeal, you and any person you have chosen to help you can see the health records and criteria your Plan used to make the decision. If you choose to have someone help you, you must give them written permission.

Expedited (faster) appeals

You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health or to your ability to regain your good health. This faster review is called an "expedited appeal."

Your provider can ask for an expedited appeal by calling us at 1-855-738-0004.

You can ask for an expedited appeal by phone, by mail or by fax. There are instructions on your Appeal Request Form that will tell you how to ask for an expedited appeal.

Provider requests for expedited appeals

If your provider asks us for an expedited appeal, we will give a decision no later than 72 hours after we get the request for an expedited appeal. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within three days from your appeal.

Member requests for expedited appeals

AmeriHealth Caritas North Carolina will review all member requests for expedited (faster) appeals. If a member's request for an expedited appeal is denied, we will call right away. We will usually call within two hours of the decision. We also will tell the member and the provider in writing if the member's request for an expedited appeal is denied. We will tell you the reason for the decision. The Plan will mail you a written notice within two calendar days.

When the member does not agree with the Plan's decision to deny an expedited appeal request, he or she may call and file a grievance with the Plan.

When we deny a member's request for an expedited appeal, there is no need to make another appeal request. The appeal will be decided within 30 days of your request. In all cases, we will review appeals as fast as a member’s medical condition requires

Timelines for standard appeals

If we have all the information we need, you will have a decision in writing within 30 days from your appeal. If we need more information to decide about your appeal, we will:

  • Write to you and tell you what information is needed
  • Explain why the delay is in your best interest
  • Decide no later than 14 days from the day we asked for more information

If you need more time to gather records and updates from your provider, just ask. You or a helper you name may ask us to delay your case until you are ready. Ask for an extension by calling Member Services at 1-855-375-8811 (TTY 1-866-209-6421) or writing to AmeriHealth Caritas North Carolina, P.O. Box 7378, London, KY 40742-7378.

Decisions on appeals

When we decide your appeal, we will send you a letter. This letter is called a Notice of Decision. If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within 120 days from the day you get your Notice of Decision.

For assistance with requesting a State Fair Hearing, please contact Member Services at 1-855-375-8811 (TTY 1-866-209-6421). You can call 24 hours a day, seven days a week. If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing to appeal to the Superior Court.

You can also contact the NC Medicaid Ombudsman at 1-877-201-3750 to get more information about your options. See page 60 of the member handbook for more information about the Ombudsman Program.

Continuation of benefits during an appeal

Sometimes a Plan's decision reduces or stops a health care service you are already getting. You can ask to continue this service without changes until your appeal is finished. You can also ask the person helping you with your appeal to make that request for you.

The rules in the section are the same for Appeals and State Fair Hearings.

There are special rules about continuing your service during your appeal. Please read this section carefully!

You will get a notice if AmeriHealth Caritas North Carolina is going to reduce or stop a service you are receiving. You have 10 days from the date we send the letter to ask for your services to continue. The notice you get will tell you the exact date. The notice will also tell you how to ask for your services to continue while you appeal.

If you ask for your services to continue, AmeriHealth Caritas North Carolina will continue your services from the day you ask for them to continue until you the day get your appeal decision. You or your authorized representative may contact Member Services at 1-855-375-8811 (TTY 1-866-209-6421) or contact the Appeals Coordinator on your adverse benefit determination letter to ask for your service to continue until you get a decision on your appeal.

Your appeal might not change the decision the health plan made about your services. When this happens, Medicaid allows the Plan to bill you for services they paid for during your appeal.

Sometimes your provider makes a new request for less of your service than you were getting. When you appeal and ask for your service to continue, you will get the level of services that your provider asked for in the new request. You will not get your old approval extended.