Filing an Appeal
There may be times when Peach State Health Plan will not pay for services that have been recommended by your doctor. If we do this, a letter will be mailed to you and your provider for services that are not approved. This letter is called a notice of Adverse Benefit Determination letter (formally known as Notice of Proposed Action letter or a denial). The adverse benefit determination letter will explain how you, someone on your behalf or your doctor (with your consent) can ask for an administrative review (appeal) of the decision.
An Adverse Benefit Determination is when Peach State Health Plan:
- Denies the care you want.
- Decreases the amount of care.
- Ends care that has already been approved.
- Denies payment for care. You may have to pay for it.
I want to ask for an appeal. How do I do it?
An appeal may be filed orally by phone, or in writing (mail or fax). This needs to be within 60 calendar days of when you get the notice of adverse benefit determination (denial notice).
There are two ways to file an appeal:
Who may file an appeal?
- You the enrollee
- A person named by you (your authorized Representative)
- A provider acting for you with your written consent.
You must give written permission if a provider files an appeal for you. Peach State Health Plan will include a form in the Notice of Adverse Benefit Determination letter called ‘Appointment of Representation’. Contact us if you need help filing the appeal.
What else do I need to know about the appeal process?
- When we get your appeal request, we will send you a letter within 10 calendar days. This will tell you we got your appeal.
- You may ask for a free copy of the guidelines, records or other information used to make this ruling.
- We’ll tell you what the ruling is within 30 calendar days of getting your appeal request.
What if I have more information I want you to have?
If you have more information to give us, bring it in person or mail it to the Grievance & Appeals address above. Also, you can look at your medical records and information on this ruling before and during the appeal process.
What can I do if I think I need an urgent or expedited appeal?
You, your doctor or someone on your behalf can ask for an urgent or expedited appeal if:
- You think the time frame for a standard appeal process could seriously harm your life or health or ability to attain, maintain or regain maximum function, based on a prudent layperson’s judgment
- In the opinion of your doctor who has knowledge of your medical condition, a standard appeal would subject you to severe pain that cannot be well-managed without the care or treatment that is the subject of the request
You, your doctor, legal representative with your consent, or legal representative of a deceased enrollee may ask for an expedited appeal by calling Member Services toll free at 1-800-704-1484, TTY/TDD 1-800-255-0056 Monday through Friday from 8 a.m. to 7 p.m. Eastern time. Peach State Health Plan will look at your request and judge if your request deserves a fast decision. If we decide your case requires a fast decision, we will make a decision and provide a determination within 72 hours.
If the request for an expedited appeal is denied:
- The appeal will be transferred to the time frame for standard resolution
- You will be notified of this decision within 2 calendar days
The time frame for an appeal may be extended up to 14 calendar days if:
- You ask for an extension
- Peach State Health Plan finds additional information is needed, and the delay is in your interest
If you have a special need, we will give you extra help to file your appeal. Please call Member Services at 1-800-704-1484, TTY/TDD 1-800-255-0056 Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
What if I do not like the outcome of the appeal?
If you do not like the outcome of Peach State’s decision, you have a right to request a State Fair Hearing (formally known as Administrative Law Hearing).
A State Fair Hearing is a hearing before an Administrative Law Judge when you want Peach State Health Plan to reconsider and change a decision or action we have made about what services are covered for you or what we will pay for a service.
A request for a State Fair Hearing must be made in writing within 120 calendar days from the date of the Appeal Decision Notice. You can request this review in writing. When you request this in writing, you will include your request for a hearing, along with a copy of the appeal determination letter.
If you want your benefits to continue, while awaiting the completion of your State Fair Hearing, you must request a continuation of care, in writing, within ten (10) calendar days from the date we mailed the Appeal Decision Notice, which can be up to 120 calendar days. But you may have to pay for this care, if the decision is not in your favor. Please see the section Continuation of Benefits below.
You must complete the Appeal process before proceeding to the State Fair Hearing. Your provider cannot request a State Fair Hearing on your behalf. You or your appointed representative or a representative of a deceased enrollee's estate can attend the State Fair Hearing.
Your request for a State Fair Hearing must be sent to the following address:
Peach State Health Plan
State Fair Hearing (Administrative Law Hearing)
1100 Circle 75 Pkwy
Atlanta, GA 30339
The Office of Administrative Hearings will tell you the date, time, and place of the hearing. You can speak for yourself or your representative may speak for you. You can get help from a lawyer. You may be able to get free legal help. The decision reached by the State Fair Hearing is final. Peach State Health Plan will comply with the State Fair Hearing decision.
If you need help requesting a State Fair Hearing or need an interpreter, call Member Services at 1-800-704-1484. If you are hearing impaired, please call our TDD/TTY line at 1-800-255-0056.
Continuation of Benefits:
If you want your benefits to continue while awaiting the completion of your Appeal Review or State Fair Hearing process, you must request a continuation of care on or before the later of the following:
- Within ten (10) calendar days from the date we mailed you the notice that we would not cover or pay for a service.
- Before the intended effective date of the notice of Adverse Benefit Determination Peach State Health Plan will continue the benefit if:
- The review must be about termination, suspension, or reduction of a previously authorized course of treatment
- The appeal was filed timely
- You have requested the continuation of benefits
- The services were ordered by an authorized Provider
- The original period covered by the original authorization has not expired
Peach State Health Plan will continue your benefits until:
- You withdraw the Appeal or State Fair Hearing request
- Ten (10) calendar days after Peach State Health Plan mails the Notice of Adverse Action unless you request within 10 calendar days a State Fair Hearing you will receive continuation of benefits until a decision is made.
- A decision is made during the Appeal Review or State Fair Hearing and is not in your favor.
- The time period or service limits of a previously authorized service has been met.
You may have to pay for the cost of continuation of your benefits if the final decision is not in your favor. If the decision is made in your favor, Peach State Health Plan will approve and pay for requested services that are needed but were not received during the review of your case as quickly as possible. If the decision is made in your favor and you did receive continuation of benefits during the review of your case, Peach State Health Plan will pay for those services.