Medicaid Choice Grievances and Appeals

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WHAT IS A GRIEVANCE?

A grievance is when you are not happy with something that DHMC does. This could be when you are not happy with:

  • The quality of care or service you get
  • The way DHMC treats you
  • Things DHMC does that you are not happy with
  • A failure to respect your rights as a member

You can file a grievance at any time to tell us (verbal or written) when you are not happy with your service or care.

WHAT TO DO IF YOU HAVE A GRIEVANCE

If you have a grievance, you or your Designated Personal Representative (DPR) can call Grievances and Appeals at 303-602-2261. You or your DPR can also write to Grievances and Appeals. Please be sure to include your name, Medicaid ID number (a letter and 6 numbers located on your card), address and phone number on your letter if you write to DHMC Grievances and Appeals. You may also fill out the Complaint and Appeal form and send it in.

Please send your written grievance to this address:

Denver Health Managed Care
Attn: Grievances and Appeals Department
777 Bannock St, MC 6000
Denver, CO 80204-4507

You will not lose your Health First Colorado Enrollment benefits by filing a grievance. It is the law!

AFTER YOU FILE A GRIEVANCE

After you file your grievance, DHMC will send you a letter within two working days to let you know that your grievance was received. DHMC will look into the details of your grievance and will decide how to handle it (in other words, DHMC will try to resolve your grievance). The DHMC staff members who make decisions on your grievance will not be the same people who you are filing your grievance about. If you file a grievance because you feel you got poor medical care or because DHMC denied your expedited appeal request, a DHMC staff member with appropriate medical training will look into your grievance.

DHMC will make a decision on your grievance and send you written notice as soon as your health condition requires, but no later than 15 working days from the day you file your grievance. The written notice will explain the results of DHMC’s decision on your grievance and the date DHMC made that decision.

You or DHMC can extend the timeframe that DHMC has to make a decision on your grievance. If you ask for more days or if DHMC believes that more facts are needed to make a decision on your grievance, DHMC may add 14 more calendar days. DHMC will only extend this timeframe if it is in your best interest. If DHMC extends the timeframe to decide on your grievance and you did not ask for the extension, DHMC will send you written notice of the reason for the delay.

IF YOU NEED HELP FILING A GRIEVANCE

DHMC will help you file a grievance. If you need help filling out any forms or taking any of the steps to file a grievance, including using an interpreter or TTY services, please call Grievances and Appeals at 303-602-2261.

IF YOU ARE STILL NOT HAPPY WITH THE OUTCOME OF YOUR GRIEVANCE

If you are still unhappy with how DHMC handles your grievance, you can go to the State of Colorado. The State of Colorado's ruling is final. You can call them at 1-800-221-3943 (no charge) or you can write them at:

Department of Health Care Policy & Financing
Attn: DHMC Medicaid Choice Contract Manager
1570 Grant Street
Denver, CO 80203-1714

WHAT IS A NOTICE OF ACTION LETTER?

This is a letter that DHMC sends you if DHMC takes any action to any part of your DHMC services. An action may include:

  • When DHMC denies or limits a type or level of service you ask for
  • When DHMC reduces, suspends, or stops authorizing a service that you have been getting
  • When DHMC denies full or partial payment or your services
  • When DHMC does not give you a service in a timely manner
  • When DHMC does not resolve your appeal or grievance within the required timeframes

A Notice of Action Letter includes:

  • The action that DHMC plans to take
  • The reason for the action
  • Your right to appeal this action
  • The date when you need to appeal by
  • Your right to ask for a State Fair Hearing
  • How to ask for a State Fair Hearing
  • When you can ask to speed up the appeal process
  • How to keep getting services while the appeal or State Fair Hearing is being decided
  • When you might have to pay for those services you got while a final ruling was pending

ADVANCE NOTICE OF ACTION

DHMC must let you know about an action before the action happens. If DHMC plans to stop paying for or reducing any services you have been getting, it has to send you a Notice of Action letter 10 calendar days before the date it stops paying for or reducing services. DHMC can shorten the timeframe to five calendar days if:

  • There is fraud
  • The Member has passed away
  • The Member is institutionalized
  • The Member’s whereabouts are unknown and there is no forwarding address
  • The Member has moved out of state or outside metropolitan Denver or has become eligible for Medicaid benefits outside of state
  • The Member’s doctor orders a change in the level of care
  • Pre-admission screening of the Social Security Act
  • The Member’s safety or health is endangered
  • The medical care is urgently needed
  • You must be transferred to another facility
  • DHMC gets a letter from you saying that you no longer want services (this letter must have information that requires that your services with DHMC end)

WHAT IS AN APPEAL?

An appeal is a request that you or your DPR can make to review an action taken by DHMC. If you think an action taken by DHMC is not right, you or your DPR can call or write us to appeal the action. A provider may file an appeal for you if you make them your DPR. If you are unhappy after your appeal decisions, then you can ask for a State Fair Hearing after you have completed all the proper steps within the DHMC appeal process.

HOW TO FILE AN APPEAL

You have sixty calendar days to file an appeal after you get a notice of action letter for a new service that you are not yet getting.

To appeal an action that will stop, suspend or cut back on services you are already getting, you have to file the appeal within 10 calendar days after the date the Notice of Action letter was sent out, or on or before the intended effective date of DHMC's action.

To appeal an action you may:

  • Call DHMC Grievances and Appeals at 303-602-2261, TTY users should call 711. If you appeal an action verbally, you must also send in a written appeal (unless you have requested an expedited appeal)
  • Fill out the Complaint and Appeal form and fax to 303-602-2078 or mail to:

    DHMC Grievances and Appeals
    777 Bannock, MC 6000
    Denver, CO 80204

FILING AN EXPEDITED (QUICK) APPEAL

If your life or health is in danger and you need DHMC to make a decision on your appeal right away, you can call DHMC Grievances and Appeals Department at 303-602-2261 and request an expedited appeal. If DHMC approves your request for an expedited appeal, DHMC will make a decision on your appeal as quickly as your health condition requires, but no later than three working days from the date of your request. If DHMC denies your request for an expedited appeal, DHMC will call you to let you know your request was denied. DHMC will also send you a letter within two calendar days of your request to let you know that your request was denied. The letter will let you know that you have the right to file a grievance if you are unhappy with DHMC’s decision. You will get a written version of your appeal with this denial letter (if you filed your appeal verbally) that you must sign and send back to DHMC. DHMC will then review your appeal in the standard timeframe explained in the next section.

AFTER YOU FILE AN APPEAL

After you file an appeal, DHMC will send you a letter within two working days (unless you file an expedited appeal) to let you know your appeal was received. DHMC will look into the details of your appeal and will decide to either accept your appeal (overturn DHMC’s action) or deny your appeal (uphold DHMC’s action). The DHMC staff members who make decisions on your appeal will not be the same people who made the original decision. If you appeal an action that uses the reason “lack of medical necessity,” a DHMC staff member will review with a medical professional to make a decision on your appeal. At any time during the appeal process, you or your DPR may provide DHMC (in person or in writing) any evidence or other information to help your case. Please note that if your appeal is expedited, you have a shorter amount of time to give DHMC this information. You or your DPR may also look at your case file before and during the appeal process. Your case file includes your medical records and any other information that DHMC is using to decide on your appeal. For standard appeals, DHMC will make a decision and send you written notice of the decision no later than 10 working days from the date you file your standard appeal. For expedited appeals, DHMC will make a decision and send you written notice of the decision no later than three working days from the date you file your expedited appeal. DHMC will also try to notify you of the decision over the phone for expedited appeals. The written notice will tell you the outcome of DHMC’s decision on your appeal and the date that it was completed. If the outcome is not in your favor, the written notice will also give you information on:

  • Your right to request a State Fair Hearing and how to request one
  • Your right to ask DHMC to continue your services while the State Fair Hearing is pending and how to make that request
  • That you may have to pay for those services you get while the State Fair Hearing is pending if the State agrees with DHMC’s decision

EXTENDING APPEAL TIMEFRAMES

You or DHMC can extend the timeframe for DHMC to make a decision on your expedited or standard appeal. If you ask for more days or if DHMC believes that more facts are needed to make a decision on your appeal, DHMC may add 14 more calendar days. DHMC will only extend this timeframe if it is in your best interest. If DHMC extends the timeframe to decide on your appeal and you did not ask for the extension, DHMC will send you written notice of the reason for the delay. This written notice will also explain that you have the right to file a grievance if you do not agree with DHMC’s decision to extend the timeframe. During the extended timeframe, DHMC will make a decision and send you written notice of the decision no later than 10 working days from the date the timeframe was extended.

GETTING HELP FILING AN APPEAL

To get help filing your appeal, you can:

You will not lose your Health First Colorado benefits if you appeal an action. It is the law!

STATE FAIR HEARINGS

If you are unhappy with an action that DHMC takes, you MUST go through the appeal process explained above. You can request a formal hearing up to 120 calendar days after receiving an appeal decision that you do not agree with. This means you or your DPR have the choice to ask for an Administrative Law Judge to review an action taken by DHMC. Your provider can also ask for a review if you make them your DPR. This review is called a State Fair Hearing. You may request a State Fair Hearing when:

  • Services you seek are denied or the ruling to approve services is not acted upon in a timely manner
  • You believe the action taken is wrong

To request a State Fair Hearing, you, your DPR, or your subscribing provider must send a letter to the Office of Administrative Courts. The letter should contain all of the following:

  • Your name, address and Medicaid ID number (a letter and 6 numbers)
  • The action, denial or failure to act quickly on which the request appeal is based
  • The reason for appealing the action, denial or failure to act quickly

At the hearing, you can represent yourself or use a provider, legal guide, a relative, a friend, or other spokesperson. You or your representative will have a chance to present evidence to the Administrative Law Judge to support your case. You or your representative may also ask for records that pertain to your appeal. If you would like someone else to represent you, you must fill out the State Fair Hearing written consent form called Representative Authorization. This form is on the State of Colorado’s website under the Department of Personnel and Administration, Office of Administrative Courts. The person you put on the form is called your authorized representative. You have to request a State Fair Hearing within 120 calendar days from the notice of action to:

Office of Administrative Courts
1525 Sherman Street, 4th floor
Denver, CO 80203

If you need help requesting a State Fair Hearing, DHMC will help you. Just call Grievances and Appeals at 303-602-2261 and ask for help. You can also call the Office of Administrative Courts at 303-866-2000. Any ruling made in a State Fair Hearing is final.

CONTINUATION OF BENEFITS DURING AN APPEAL OR STATE FAIR HEARING

In some cases, DHMC will keep covering services while you wait for the ruling of an appeal or State Fair Hearing. DHMC will keep covering your services while you wait for a ruling if:

  • You file your appeal within 10 calendar days from the date on your notice of action letter or by the effective date of DHMC’s action
  • The service(s) you are getting are from an authorized provider and your original authorization timeframe on your service(s) is not expired

But, you must still call Grievances and Appeals at 303-602-2261 and tell them that you want DHMC to keep covering your services. Your services will continue until one of the following:

  • You decide to cancel your appeal
  • 10 calendar days after the ruling of your appeal unless, within that 10 days, you request a State Fair Hearing with continuation of services until the State Fair Hearing ruling is reached
  • The State Fair Hearing office rules that DHMC does not have to pay for your services
  • The time limit on your original service authorization is up

If DHMC or the State Fair Hearing office decides to approve your appeal or State Fair Hearing (reverses the decision to deny your services), and you were getting a continuation of services while your appeal or State Fair Hearing was pending, DHMC will pay for those services. If DHMC or the State Fair Hearing office comes to a ruling that they do not agree with your appeal, you may have to pay for the services you got while waiting for DHMC or the State fair office’s ruling on the appeal. If DHMC or the State Fair Hearing office decides to approve your appeal or State Fair Hearing (reverses the decision to deny your services), and you were not getting a continuation of services while your appeal or State Fair Hearing was pending, DHMC will start paying for those services as quickly as your health condition requires.

HEALTH FIRST COLORADO (COLORADO’S MEDICAID PROGRAM) OMBUDSMAN

The Ombudsman is independent from all of the Health First Colorado health care plans. If you have a problem or concern the Ombudsman will work with both you and your doctor or health plan to find a solution that works for everyone. If you are Health First Colorado member (this includes DHMC) and have a problem with a Denver Health Provider or with your Mental Health Provider:

  • First talk with your doctor or with DHMC Member Services by calling 303-602-2116 (often this will help)
  • You can also call the Ombudsman for Health First Colorado Managed Care
    Metro area: 303-830-3560
    Out of metro area: 1-877-435-7123

Call the Ombudsman Program when:

  • You cannot get an appointment or have to wait too long for an appointment
  • You cannot see a specialist
  • You are not happy with care provided to you or a family member
  • Your health plan denied a service
  • You need help filing a grievance, complaint or appeal
  • You are not sure whom to call