What is a managed care appeal?

An appeal is your request for a review of an adverse decision. An adverse decision is when a managed care organization (such as Aetna, Sunflower or United):

• Denies or limits a service you want;
• Reduces, suspends or terminates a service you are getting;
• Fails to authorize a service in the required time.

How do I submit a managed care appeal?

The member or member’s authorized representative may submit an appeal either orally or in writing.

To submit a managed care Appeal by telephone call:

• Aetna 1-855-221-5656 TTY 711
• Sunflower 1-877-644-4623 TTY 1-888-282-6428
• United 1-877-542-9238 TTY 711

To submit a managed care Appeal by fax send to:

• Aetna 1-833-857-7050
• Sunflower 1-888-453-4755
• United Healthcare Not available

To submit a managed care Appeal by mail send to:

Aetna
Appeal and Grievance Department
9401 Indian Creek Parkway
Overland Park, KS 66210

Sunflower
Quality Department
8325 Lenexa Drive, Suite 200
Lenexa, KS 66214

United
Grievances and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

To submit a managed care Appeal in person go to:

Aetna
Appeal and Grievance Department
9401 Indian Creek Parkway
Overland Park, KS 66210

Sunflower
Quality Department
8325 Lenexa Drive, Suite 200
Lenexa, KS 66214

United
Grievances and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

Is there a deadline for filing a managed care appeal?

Yes, the member or member’s representative must submit a request for an appeal with the MCO within 63 calendar days from the date of the notice of the adverse benefit determination.

What happens once a managed care appeal has been submitted?

The MCO will acknowledge each oral or written appeal received from a member or their authorized representative in writing within 5 calendar days of receipt.

For expedited appeal requests, the MCO is not required to issue an acknowledgement, but will acknowledge receipt of the expedited appeal request in the notice of expedited appeal resolution.

The MCO will resolve each appeal and provide notice as quickly as the member’s health condition requires and not later than 30 calendar days from the date the MCO receives the appeal.

What documents do I need to submit for my managed care appeal?

Call your MCO or send in your appeal letter as soon as possible saying you want to appeal. It does not have to state your case.

Follow up with documentation showing why you are appealing the case and disagree with the decision. It can be a letter from yourself or a professional that can identify:

• The change that has been determined by the managed care organization
• Why this should not be done and the problems it will cause
• The effect it will have short and long-term on the physical, mental, and emotional well-being of the member
• For HCBS members you may include a copy of your current Integrated Service Plan (ISP) (plan of care) and the new one with the changes.

What happens to my services while I am appealing a managed care decision?

Non-HCBS Services

If you want your services continued during an appeal, you have 10 calendar days from the mailing date on the “Notice of Adverse Benefit Determination Letter” to ask the MCO to continue your services during the appeal process.

If you request an appeal within 63 calendar days from the date of the notice, the MCO will continue your current level of services until they issue a notice of appeal resolution. The MCOs must issue the notice of appeal resolution within 30 calendar days after receiving your appeal.

If the MCO does not change their decision, you may ask for a state fair hearing. You must ask for the state fair hearing within 123 calendar days from the date of the appeal resolution notice.

If you want your services to continue during the state fair hearing process, you must ask the MCO within 10 calendar days from the mailing date of the appeal resolution notice.

If the state fair hearing officer changes the MCO's decision, and the Member received the services while the state fair hearing was pending, the MCO must pay for those services.

Please keep in mind that you may have to pay for the continued services if you lose the appeal or state fair hearing.

Home and Community Based Services (HCBS)

If you receive a “Notice of Adverse Benefit Determination Letter” that your HCBS services will be changing, the MCO will automatically continue your current HCBS services for 63 calendar days from the date of the notice to allow you time to ask for an appeal. If you do not ask for an appeal, the current level of HCBS services will change.

If you request an appeal within 63 calendar days from the date of the notice, the MCO will continue your current level of HCBS services until they issue a notice of appeal resolution. The MCOs must issue the notice of appeal resolution within 30 calendar days after receiving your appeal.

If the MCO does not change their decision, you may ask for a state fair hearing. The MCO will automatically continue your current HCBS services for 123 calendar days from the date of the appeal resolution notice to allow you time to ask for a state fair hearing. If you do not ask for a state fair hearing, the current level of HCBS services will change.

If you ask for a state fair hearing within 123 calendar days from the date of the appeal resolution notice, the MCO will continue your current level of HCBS services until the hearing decision.

If the state fair hearing officer changes the MCO's decision, and the Member received the HCBS services while the state fair hearing was pending, the MCO must pay for those services.

You will not have to pay for the continued services if the appeal decision or state fair hearing decision are not in your favor unless fraud is present.

What is an expedited managed care appeal?

If you received an adverse decision from the MCO, you can ask for a fast appeal (expedited appeal). You can ask in writing or verbally (by phone). If you or your provider believe you have an urgent medical need, you may ask the MCO for a fast appeal. The MCO will decide if you qualify for a fast decision. If you qualify, the MCO will make a decision about your fast appeal within 72 hours or less after the MCO receives it.

What happens if you think it should be expedited but the MCO does not?
If you did not qualify for a fast appeal decision, the MCO will make a decision and send an appeal resolution notice within 30 calendar days.

Can you ask for a fast State Fair Hearing?
If you qualified for a fast appeal decision, and the MCO did not change their decision, you may ask for an expedited State Fair Hearing.