Filing an Appeal
What is an Appeal?
When a claim or service are denied you will receive a “Notice of Adverse Action”. This letter will explain the denial or limited authorization of a request, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Coordinated Care network.
An appeal is a request for Coordinated Care to reconsider or change a decision that is on your “Notice of Adverse Action”. An appeal may be filed to reconsider, for example, a denied claim or service. You or your authorized representative (with written consent from you) may appeal any adverse decision.
How do I file an Appeal?
An appeal may be filed verbally or in writing, and received by mail, telephone, fax, email, or in person. The health plan will acknowledge, in writing, the receipt of the appeal within 72 hours of receiving the appeal. An appeal request must be filed within 60 calendar days of the date on the plan’s notice of adverse action to you.
Who can file an Appeal and how are they reviewed?
A member, the member’s authorized representative (PDF) or a provider acting on behalf of the member, and with the member’s written consent, may file an appeal either orally or in writing. Oral appeals must be confirmed in writing unless the request is for an expedited appeal. For standard authorization decisions, the appeal must be filed within 60 calendar days of the date on the Notice of Adverse Action. If the member is requesting continuation of services while the appeal is being reviewed, the appeal must be submitted within 10 calendar days of the Notice of Adverse Action.
A member may review the appeal case file and submit additional information to be considered as part of the appeal. Appeals will be reviewed by a healthcare professional with appropriate expertise in the subject of the appeal who was not involved in the original denial or determination.
What happens after I file an Appeal?
Requests for appeals within the standard timeframe must be resolved within 14 days of receipt of the appeal, with a 14 day extension possible if additional information is required. Members may request that Coordinated Care review the Notice of Adverse Action to verify if the right decision has been made.
Expedited appeals may be filed when either Coordinated Care or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals. Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 3 calendar days from the initial receipt of the appeal. Coordinated Care shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.
If the member does not agree with the resolution of an appeal, the member or the member’s authorized representative may request an Administrative Hearing. Providers may not request a hearing on behalf of a member. After exhausting both Coordinated Care's appeal process and the hearing process, a member has the right to an independent review of the request in accordance with RCW 48.43.535 and WAC 182-538.