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Appeal Review

An appeal is a written or oral request from a member, or a provider acting on behalf of the member with member consent, for the reversal of an action which is defined as:

  • The denial or limited authorization of a requested service, including the type or level of service.
  • The reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service.
  • The failure to provide services in a timely manner (as defined by Louisiana Department of Health).
  • The failure of the CCN to act within the timeframes for the resolution of grievances and appeals as described in 42 CFR §438.400(b).

Example of an appeal includes, but is not limited to:

  • A provider submits an authorization request for an inpatient procedure such as a hysterectomy. The AmeriHealth Caritas Louisiana Medical Director reviews the request and denies it due to not meeting medical necessity criteria. The provider can appeal the authorization denial on behalf of the member, with member consent.

Filing a request for an appeal review

Members, or providers acting with the consent of the member, may request an appeal review by submitting the request in writing within 60 calendar days of the date of the denial or adverse action by AmeriHealth Caritas Louisiana. The request must be accompanied by all relevant documentation the member, or provider acting on behalf of the member, would like AmeriHealth Caritas Louisiana to consider during the appeal review.

Requests for a member appeal review, including providers appealing on behalf of the member, should be mailed to the appropriate post office box below and must contain the word “Appeal" at the top of the request:

Appeal
Appeals Department
P.O. Box 7328
London, KY 40742

AmeriHealth Caritas Louisiana will send the member a letter acknowledging AmeriHealth Caritas Louisiana's receipt of the request for an appeal review within five calendar days of AmeriHealth Caritas Louisiana's receipt of the request from the member, or provider acting on behalf of the member.

Physician review of an appeal

The appeal review is conducted by a medical director or physician designee who was not involved in the decision-making for the original denial or prior reconsideration of the case. The medical director or physician designee will issue a determination to uphold, modify, or overturn the denial based on:

  • Clinical judgment.
  • Established standards of medical practice.
  • Review of available information including but not limited to:
    • AmeriHealth Caritas Louisiana's medical and administrative policies.
    • Information submitted by the member or health care provider acting on behalf of the member, or information obtained by AmeriHealth Caritas Louisiana through investigation.
    • The network provider's contract with AmeriHealth Caritas Louisiana.
    • AmeriHealth Caritas Louisiana's contract with the State of Louisiana's Medicaid Program and relevant Medicaid laws, regulations, and rules.

Time frame for resolution of an appeal

Members will be notified in writing of the determination of the appeal review, including the clinical rationale, within 30 calendar days of AmeriHealth Caritas Louisiana's receipt of the member’s, or health care provider acting on behalf of the member, request for the appeal review.

Expedited appeals

An expedited appeal may be requested if the member or member's representative believes the member's life, health, or ability to attain, maintain, or regain maximum function would be placed in jeopardy by following the standard appeal process. An expedited appeal review may be requested either verbally or in writing.

AmeriHealth Caritas Louisiana must conduct an expedited review of an appeal at any point prior to the appeal decision. A signed provider certification that the member's life, health, or ability to attain, maintain, or regain maximum function would be placed in jeopardy by following the standard appeal process must be provided to AmeriHealth Caritas Louisiana per CFR 42 Sec. 438.410 (a). The provider certification is required regardless of whether the expedited appeal is filed verbally or in writing by the member or the provider acting on behalf of the member.

Upon receipt of a verbal or written request for expedited review, AmeriHealth Caritas Louisiana verbally informs the member or member's representative of the right to present evidence and allegations of fact or of law in person, as well as in writing, and of the limited time available to do so.

If an expedited appeal is filed to dispute a decision to discontinue, reduce, or change a service/item that the member has been receiving, then the member will continue to receive the disputed service/item at the previously authorized level, pending resolution of the expedited appeal, if the expedited appeal is hand-delivered or post-marked within 10 days from the mail date on the written notice of the decision. AmeriHealth Caritas Louisiana also honors a verbal filing of an expedited appeal within 10 days of receipt of the written denial decision in order to continue services.

The expedited appeal review is performed by the expedited appeal review committee, which shall include a licensed physician. The committee receives a written report from a licensed physician or other appropriate provider in the same or similar specialty that typically manages or consults on the service/item in question.

The expedited appeal review process is bound by the same rules and procedures as the appeal review process with the exception of time frames, which are modified as specified in this section.

AmeriHealth Caritas Louisiana issues the decision resulting from the expedited review in person or by phone to the member and other appropriate parties within 72 hours of receiving the member's request for an expedited review. In addition, AmeriHealth Caritas Louisiana mails written notice of the decision to the member and other appropriate parties within two days of the decision.

Oral requests for expedited appeals are committed to writing by AmeriHealth Caritas Louisiana and provided to the member and other appropriate parties via the decision letter. The member or member's representative may file a request for a fair hearing within 30 days from the mail date on the written notice of the expedited appeal decision.