Alliance has the authority to make decisions about Medicaid services because we have a contract with the North Carolina Medicaid agency pursuant to 42 C.F.R. Part 438. We can only approve services that are medically necessary. We base our decision to approve or deny a request for Medicaid services on 10A NCAC 25A .0201, the North Carolina State Plan for Medical Assistance, Medicaid Clinical Coverage Policies, the North Carolina MH/I-DD/SA Health Plan Waiver and the NC Innovations Waiver, and established Clinical Practice Guidelines. If you don’t have internet access or want us to send you a copy of these documents you can call (800) 510-9132.
Attorneys or other individuals wishing to assist a consumer in the appeals process must submit this Consent to Release Personal and Medical Information signed by the consumer or guardian before Alliance can share Protected Health Information.
Appealing a Denial for Medicaid Services
Alliance will notify you in writing within one business day of any denial of Medicaid-funded service by sending you a Notice of Action letter. This letter tells you why the service request was denied and it contains the Request for LME/MCO Level Appeal form. This form can be used to ask Alliance to reconsider a decision to deny a service request. The questions and answers below will provide additional information and instruction about the appeals process.
Per 10A NCAC 27G .7004 you may file an appeal for a denial, reduction, termination or suspension of a State or locally-funded non-Medicaid service. The first step in that process is to request a Local Appeal. Alliance will notify you in writing within one business day of any denial of local services by sending you a Notice of Decision letter. This letter tells you why the service request was denied and the last page of this letter is the Request for Local Appeal form. The Request for Local Appeal form is required when asking that Alliance reconsider decision to deny a service request. This letter also tells you more about the appeals process for local services and that information is listed below:
- The Request for Local Appeal form must be received by Alliance within 15 working days of this notice (10A NCAC 27G.7004). If the deadline falls on a weekend or holiday, then it is due the next business day. This due date is noted on the Request for Local Appeal form.
- Your provider or someone else can help you with the Request for Local Appeal form and process if you give them written permission on the form.
- You can ask for your Local Appeal to be decided sooner if you think that waiting 7 days might seriously jeopardize your life, health or functional abilities. Alliance will contact you within 72 hours of receiving your request for an expedited Local Appeal to inform you of when the review will be completed.
Someone from Alliance will respond to you within three days of receipt of your request for Local Appeal. You may have someone with you at any meeting that is held to discuss the appeal. This includes, but is not limited to, advocates, personal supporters or a legally-responsible person. For further information on the appeal process or to seek assistance in completing the appeal contact the Alliance Appeals Department at (919) 651-8545.
Note that appeals for the denial for county-funded inpatient services at Holly Hill Hospital follow the process outlined within the contract between Holly Hill Hospital and Alliance and can be explained to you by contacting Alliance’s Appeals Department at (919) 651-8545.
Attorneys or other individuals wishing to assist an individual in the appeals process must submit this Consent to Release Personal and Medical Information signed by the consumer or guardian before Alliance can share Protected Health Information.