Managed Care Appeals and Grievances

Whenever an MCO takes an “action” that you disagree with you can file an appeal. If you are a member of a Medicaid managed care plan, there are two levels of appeal. The first level of appeal is a request for the MCO to review any “action” it has taken. When an MCO takes an “action”, you must go through the MCO’s appeals process  before requesting a fair hearing with the State.

You may file an appeal if you disagree with any of the following MCO “actions:”

• A decision to deny or provide only limited authorization of a requested health care service.
• A decision to reduce health care services that you are getting.
• A decision to limit health care services that you are getting.
• A decision to suspend a health care service that you are getting.
• A decision to end a health care service that you are getting.
• Not receiving health care services in a timely manner.
• The failure of your MCO to act within the timeframes required for resolution of a grievance, standard resolution of an appeal, or expedited resolution of an appeal.

If your MCO denies, reduces, limits, suspends or ends health care services, the MCO is required to send you a written notice telling you about this decision.  MCOs are required to give you a written notice if it takes any of the above actions, at least 10 days in advance of the action. The written notice must contain certain elements, including explaining the action the MCO has taken or intends to take, the reasons for the action, and the specific legal basis that supports it.  It must also include information about the appeal process.  It is very important to review the notice carefully and follow the deadlines for the appeal process.

You may file your appeal over the phone or in writing. An oral request for an appeal must be followed by a written and signed appeal request unless the request is for an expedited resolution. You may also designate someone to file the appeal for you, including your provider. You must give written permission to name another person to file an appeal for you. Each MCO has its own appeal process. The chart below contains information about how to file an appeal with each MCO.  You must file your appeal with the MCO within 60 days of the date of the MCO’s written notice.  To assure your services continue pending your appeal to the MCO, you must specifically request continuation of benefits and appeal within 10 calendar days from the date you receive the notice of action.

You may lose your right to appeal an MCO action or your right to continued services if you do not file within these timeframes.  You have the right to file an appeal even if no notice was sent.

After your appeal is filed, the MCO must provide a reasonable opportunity for you to present evidence, and allegations of fact or law, in person as well as in writing.  Additionally, the MCO must allow you to review your case file, including medical records and any other documents and records the MCO considered as part of your appeal.  You have the right to receive a copy of your records upon request free of charge.

MCOs are required to issue a written decision within 30 calendar days after receipt of your appeal request.  The MCO is permitted to request an extension of up to 14 calendar days if:

1) you request the extension, or

2) if the MCO shows that there is a need for additional information and the MCO can show that the extension is in your best interest.

If taking the time for standard resolution of your appeal would seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function, you may request expedited resolution of your appeal.  If the MCO accepts your request for an expedited appeal, they must resolve it as “expeditiously as the member’s health condition requires”, but no later than 3 calendar days after the MCO received your request.

If the MCO denies your request for an expedited appeal, it must make “reasonable efforts” to give you prompt verbal notice of the denial and then must provide written notice of the denial within 2 calendar days.  You have the right to file a grievance with the MCO if it denies your request for an expedited appeal.  It is important to note that if the MCO denies your request for an expedited appeal, it must then treat your appeal as part of the standard appeal process.

Whenever you appeal an MCO’s decision to deny, reduce, limit, suspend or end health care services, you have a right to continued benefits pending the resolution of your appeal to the MCO so long as:

1) you specifically request continuation of benefits and

2) you appeal within 10 calendar days from the date you receive the notice of action. The date on which you receive the notice is considered to be 5 days after the date on the notice, unless you can show that you did not receive the notice within the 5–day period.

If you are unhappy with the MCO’s resolution of your appeal, you may appeal that decision to the State by requesting a fair hearing. This is the second level of appeal. You cannot request a fair hearing without first going through the MCO’s appeal process.  You must file your request for a fair hearing with the State within 120 days of the date of the MCO’s written decision on your appeal. To ensure services continue pending your appeal to the State, you must specifically request continuation of benefits and request a fair hearing within 10 calendar days from the date you receive the MCO’s decision on your appeal.

You may lose your right to appeal or your right to continued services if you do not file within these timeframes.  You have the right to request a fair hearing even if the MCO failed to provide a written decision on your appeal.

To request a fair hearing with the State, write to:
Administrative Appeals Unit
Office of Operations Support
NH Department of Health & Human Services
105 Pleasant Street
Concord, NH  03301
1-800-852-3345 extension 4292
Fax: 603-271-8422

In New Hampshire, Medicaid fair hearings are usually held at the Administrative Appeals Unit in Concord or at your local District Office.  A hearing officer from the Administrative Appeals Unit will conduct the hearing. Medicaid beneficiaries have a number of important procedural rights associated with fair hearings.

Learn more about your Fair Hearing Rights

Pursuant to federal law, the State is required to issue a written decision within 90 days of the date you first requested your appeal to the MCO.  This does not include the number of days it took for you to request a fair hearing with the State.

Whenever you appeal an MCO’s decision to deny, reduce, limit, suspend or end health care services, you have a right to continued benefits pending the resolution of your fair hearing appeal so long as:

1) you specifically request continuation of benefits and

2) you appeal within 10 calendar days from the date you receive the MCO’s written decision on your appeal. The date on which you receive the decision is considered to be 5 days after the date on the decision, unless you can show that you did not receive the decision within the 5–day period. Even if you requested continued benefits during your appeal to the MCO, you must request it again to have continued benefits pending resolution of your fair hearing.

If you lose your fair hearing, you may be responsible for the cost of continued benefits provided pending the appeal.

In addition to filing a grievance or appeal, you can contact the the Department of Health and Human Services Ombudsman’s Office at 603-271-6941, 603-271-5573, or 1-800-852-3345 ext. 6941 to discuss your issues. While the Office of the Ombudsman cannot overturn the decision of an MCO, it may be able to provide information on how to file an appeal or grievance or intervene on your behalf to resolve any conflict. It is important, however, that you file your appeal and/or grievance first, then contact the Office of the Ombudsman so you do not miss any deadlines and lose your right to appeal.

A grievance is like a complaint.  A grievance can be filed if you are dissatisfied with your Medicaid managed care plan for any reason other than the “actions” listed in the appeals section. You can file a grievance if you are dissatisfied with the quality of care or services provided, the way you are treated by your plan’s employees, providers or contractors, or if you believe the MCO is not respecting your rights.

You may make your grievance over the phone or in writing. Writing is preferred, and keep a copy for your records. You may also designate someone to make the grievance for you.  Each MCO has its own internal grievance process.

MCOs are required to resolve a grievance and provide notice to members as “expeditiously as the member’s health condition requires”, but not later than 45 calendar days from the date the MCO received the grievance.  Each MCO has its own process for receiving and resolving member grievances.

MCOs are required to respond in writing to grievances involving clinical issues.  If your grievance does not involve a clinical issue, the MCO may respond to your grievance over the phone.  An example of a non-clinical grievance is a complaint that an MCO employee was rude to you over the phone.

You do not have the right to appeal the MCO’s response to your grievance.   However, you have the right to voice any concerns to New Hampshire Medicaid at any time. You may contact New Hampshire Medicaid Client Services by phone at 1-800-852-3345, extension 4344 or 603-271-4344.

In addition to filing a grievance or appeal, you can contact the Department of Health and Human Services Ombudsman’s Office at 603-271-6941, 603-271-5573, or 1-800-852-3345 ext. 6941 to discuss your issues. While the Office of the Ombudsman cannot overturn the decision of an MCO, it may be able to provide information on how to file an appeal or grievance or intervene on your behalf to resolve any conflict. It is important, however, that you file your appeal and/or grievance first, then contact the Office of the Ombudsman so you do not miss any deadlines and lose your right to appeal.