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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.