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Fair hearing procedures

Standard fair hearing

Members or member representatives may request a fair hearing within thirty (30) days from the mail date on written notice of grievance or appeal decision.

Members, or providers filing on behalf of a member, must exhaust AmeriHealth Caritas Louisiana's standard or appeal processes before filing a fair hearing Request.

Member can make the request for a fair hearing through AmeriHealth Caritas Louisiana who will submit the request and Summary of the case to the Division of Administrative Law or by filing directly with the Division of Administrative Law. The request for a fair hearing must include a copy of the written notice of decision that is the subject of the request. Requests must be sent to:

Division of Administrative Law (DAL)
Health and Hospitals Section
Post Office Box 4189
Baton Rouge, LA. 70821-4189
Phone: (225) 342-0443
Fax: (225) 219-9823
Phone for oral appeals: (225) 342-5800

A member who files a request for a fair hearing to dispute a decision to discontinue, reduce or change a service/item that the member has been receiving must continue to receive the disputed service/item at the previously authorized level pending resolution of the fair hearing, if the request for a fair hearing is hand delivered or post-marked within ten (10) days from the mail date on the written notice of decision.

Upon receipt of the request for a fair hearing, the Divison of Administrative Law (DAL) designee will schedule a hearing. The member and AmeriHealth Caritas Louisiana will receive notification of the hearing date by letter at least ten (10) days in advance, or a shorter time if requested by the member. The letter will outline the type of hearing, the location of the hearing (if applicable), and the date and time of the hearing.

AmeriHealth Caritas Louisiana is a party to the hearing and must be present. AmeriHealth Caritas Louisiana, which may be represented by an attorney, must submit the Summary of Evidence (SOE) and be prepared to explain and defend the issue on appeal. AmeriHealth Caritas Louisiana must submit the SOE packet to the Division of Administrative Law within seven (7) calendar days of receipt of the request for State fair hearing if the request is made directly to AmeriHealth Caritas Louisiana.

AmeriHealth Caritas Louisiana will provide the member, at no cost, with records, reports, and documents, relevant to the subject of the fair hearing.

The fair hearing decision will be issued within ninety (90) days the the filing and is binding on AmeriHealth Caritas Louisiana If the Division of Administrative Law rules in favor of the claimant/appellant, AmeriHealth Caritas Louisiana will receive a directive from the Division of Administrative Law. The directive shall be executed within ten days and reported to the DHH within 14 days of the date of the directive or by the state level appeal's 90th day deadline, whichever is earliest.

PROVISION OF AND PAYMENT FOR SERVICES/ITEMS FOLLOWING DECISION

If AmeriHealth Caritas Louisiana or the DAL reverses a decision to deny, limit, or delay services/items that were not furnished during the grievance, appeal or fair hearing process, AmeriHealth Caritas Louisiana will authorize or provide the disputed services/items promptly and as expeditiously as the member's health condition requires.

If AmeriHealth Caritas Louisiana or the DAL reverses a decision to deny authorization of services/items, and the member received the disputed services/items during the complaint, appeal or fair hearing process, the plan will pay for those services/items within 10 days or the fair hearing decision 90th day timeline, whichever is earliest.