Elevate Medicaid Choice Complaints and Appeals

After you file a complaint, Elevate Medicaid Choice will send you an acknowledgement letter. This letter is to let you know it was received and summarize the complaint. They have two working days to send it to you. They will review it and take steps to solve it. The staff who makes rulings on your complaint are not the same people you filed your complaint about. An Elevate Medicaid Choice staff person with the right health training will review your complaint if:

• You feel you got poor care
• Elevate Medicaid Choice denied your sped up appeal request

Elevate Medicaid Choice will rule on your complaint and send you a written notice. They will send it as soon as your health issue needs. The written notice will tell you Elevate Medicaid Choice’s ruling on your complaint. It will also have the date Elevate Medicaid Choice made that finding. 

You or Elevate Medicaid Choice can stretch out the timeframe for Elevate Medicaid Choice to rule on your complaint. You can ask for more days. You or Elevate Medicaid Choice can add (14) more days to the timeframe. Elevate Medicaid Choice can ask for more days if they need more facts to rule on your complaint. Elevate Medicaid Choice will only stretch out this timeframe if its best for you. If Elevate Medicaid Choice stretches the timeframe, they will send you a letter. If you did not ask for more time, they will send you a reason.

Elevate Medicaid Choice will help you file a complaint for free. They can help to fill out forms or file a complaint. If you need a translator or TTY, please call Complaints and Appeals at 303-602-2261.

If you are still not happy with how Elevate Medicaid Choice handles your complaint, 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: Elevate Medicaid Choice Contract Manager
1570 Grant St.
Denver, CO 80203-1714

You have (60) days to file an appeal from the date on the Notice of Adverse Benefit Determination letter was mailed for a new kind of care that you are not yet getting. 

To appeal an action that will stop, suspend or cut back on care you are now getting, file the appeal in (10) days of the date the Notice of Adverse Benefit Determination letter was sent out. Or file it on or before the planned start date of Elevate Medicaid Choice 's action.

DHMP will help you file an appeal. If you need help, please call Complaints and Appeals at 303-602-2261, TTY users should call 711.

Elevate Medicaid Choice Complaints and Appeals
777 Bannock St., MC6000
Denver, CO 80204

You can ask for an expedited appeal. If your life or health is in danger, a ruling can be made quickly. Call the Complaints and Appeals Department at 303-602-2261 and ask for an expedited appeal. Elevate Medicaid Choice will make a ruling as quickly as your health issue needs. They have 72 hours if your expedited request is approved. If your request for an expedited appeal is denied, you will get a call. Elevate Medicaid Choice will also send you a letter. The letter will tell you why your request was denied. The letter will be sent within two days of your request. This letter will say you have the right to file a complaint if you are not happy with Elevate Medicaid Choice’s ruling. You will get a written version of your appeal with this denial letter. (This is only if you voiced your appeal.) 

After you file an appeal, Elevate Medicaid Choice will send you a letter. This letter is to let you know your appeal was received. They will send it in two working days that they got your appeal. That is, unless you file an expedited appeal. They will look into your appeal and rule to either:

• Accept it (reject Elevate Medicaid Choice’s action), or
• Deny it (uphold Elevate Medicaid Choice’s action)
   

The Elevate Medicaid Choice staff who make rulings on your appeal will not be the same as who made the first ruling.
You can appeal an action that uses the reason lack of health necessity (need). An Elevate Medicaid Choice staff member will review this ruling with a health expert.

You or your DPR may give proof to help your case. You can give proof in writing or over the phone. If your appeal is expedited, you have a shorter amount of time. You or your DPR may look at your case file for the appeal process free of charge and sufficiently in advance of the appeal resolution timeframe. You may look before and during the appeal process. Your case file is made up of your health records. It also has any other facts being used to rule on your appeal.

For standard appeals, Elevate Medicaid Choice has 10 working days from the file date. They will rule and send you a written notice of the ruling. 

For expedited appeals, Elevate Medicaid Choice has 72 hours from the file date. They will rule and send you a written notice of the ruling. Elevate Medicaid Choice will also try to call you with the ruling. The written notice will tell you the result of Elevate Medicaid Choice’s ruling on your appeal. It will also show the date that it was done. If the ruling is not in your favor, the written notice will tell you: 

• Your right to ask for a State Fair Hearing and how to do it
• Your right to ask Elevate Medicaid Choice to keep your care while the State Fair Hearing is pending and how to do it
• That you may have to pay for the care you get while the State Fair Hearing is pending if the State agrees with Elevate Medicaid Choice’s ruling

You or Elevate Medicaid Choice can stretch the timeframe for them to rule on your appeal. You can ask for more days. Elevate Medicaid Choice can add 14 days if they think more facts are needed. Elevate Medicaid Choice will only stretch this timeframe if it is best for you. 

If Elevate Medicaid Choice stretches the timeframe, they will send you a letter. If you did not ask for more time, they will send you a reason. You have the right to file a complaint if you do not agree. During the stretched timeframe, Elevate Medicaid Choice will rule. 

To get help filing your appeal, you can:

• Call Complaints and Appeals at 303-602-2261, TTY call 711
• Call the Health First Colorado (Colorado’s Medicaid Program) ombudsman at 303-830-3560 or 1-877-435-7123

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

You may ask for a State Fair Hearing when:

• Care you seek is denied  
• The ruling to approve care is not done in a timely way
• You believe the action taken is wrong

To ask for a State Fair Hearing, you, your DPR or the provider that arranged your care must send a letter to the Office of Administrative Courts.

The letter should have these items:

• Your name, address and Medicaid ID # (a letter and 6 #s)
• The action, denial or the Plan's failure to act fast on which the request appeal is based
• The reason for appealing the action, denial or failure to act fast

At the hearing, you can represent yourself or use a:

• provider
• legal guide
• relative
• friend
• other person

You can bring items to support your case. You will have a chance to show proof to the administrative law judge. You may also ask for records that relate to your appeal. 

Someone else can represent you. You must fill out the State Fair Hearing written consent form called a 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 must ask for a State Fair Hearing in 120 days from the notice of action to:

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

Elevate Medicaid Choice can help you ask for a State Fair Hearing. Call Complaints and Appeals at 303-602-2261 . You can also call the Office of Administrative Courts at 303-866-2000. Any ruling made in a State Fair Hearing is final.

In some cases, Elevate Medicaid Choice will still cover care while you wait for the ruling of an appeal or State Fair Hearing if:

• You file your appeal in (10) days from the date on your Notice of Adverse Benefit Determination letter or by the start date of Elevate Medicaid Choice’s action
• The care you are getting from your provider is not expired. Your first approval timeframe for that care is not expired either.

You must still call Complaints and Appeals at 303-602-2261. Tell them you want Elevate Medicaid Choice to keep your care active.

You can keep your care until:

• You cancel your appeal
• 10 days after the ruling of your appeal (unless, in those 10 days, you ask for a State Fair Hearing with your care still intact until the State Fair Hearing ruling is reached).
• The State Fair Hearing office rules that Elevate Medicaid Choice does not have to pay for your care
• The time limit on your first care approval is up

Elevate Medicaid Choice will pay for your care as fast as your health issue needs. They will start paying no later than 72 hours from the date it receives notice reversing the determination if the services were not furnished while the appeal was pending.

• First talk with your provider or Elevate Medicaid Choice Health Plan Services. Call them at 303-602-2116 (often this will help) 
• Call the ombudsman for Health First Colorado Managed Care
  Metro area: 303-830-3560
  Out of metro area: 1-877-435-7123, TTY users call 711
• You can email the ombudsman at help123@maximus.com

Call the Ombudsman Program when:

• You cannot get a visit or must wait too long for a visit
• You cannot see a health expert
• You are not happy with care given to you or a family member
• Your health plan denied a service
• You need help filling out a complaint or appeal
• You are not sure who to call