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, phone, fax, email, or in person. The health plan will acknowledge, in writing, the receipt of the appeal within five calendar days of receiving the appeal. An appeal request must be filed within 60 calendar days after the date on the health plan's denial letter.
Mail: Attn: Appeals
1145 Broadway, Suite 300
Tacoma, WA 98402
Phone: 1-877-644-4613 (TTY 711])
What are the steps in the appeal process?
Step 1: Coordinated Care Standard and Expedited Appeal
Step 2: State Administrative Hearing
Step 3: Independent Review
Step 4: Health Care Authority (HCA) Board of Appeals Review Judge
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. For standard authorization decisions, the appeal must be filed within 60 calendar days of the date on the denial letter. If the member wants to keep getting previously approved services while the appeal is being reviewed, the appeal must be filed within 10 calendar days of the date of the denial letter. If the final decision in the appeal process agrees with our decision, the member may need to pay for services received during the appeal process.
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 decision.
What happens after I file an Appeal?
Requests for standard (non-urgent) appeals must be resolved within 14 calendar days of receipt of the appeal, with a 14 calendar day extension possible if additional information is required.
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 of the decision 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. The member must ask for a hearing within 120 calendar days of the date on the appeal decision letter stating the denial was upheld. The member may ask for a quick decision if the member’s health is at risk.
After exhausting both Coordinated Care's appeal process and the hearing process, a member has the right to ask for an independent review within 21 calendar days of the hearing decision in accordance with RCW 48.43.535 and WAC 182-538. The case will then be sent to an Independent Review Organization (IRO) within three working days. The member may skip the IRO and ask for a final review of their case by the Health Care Authority (HCA) Board of Appeals Review Judge. The decision of the HCA Board of Appeals is final. To request an IRO, please contact Coordinated Care.