Appeals Policies and Processes

Sometimes Alliance Health may decide to deny or limit a request your provider makes for Medicaid benefits or services offered by our plan. This decision is called an “adverse benefit determination.” You will receive a letter from Alliance Health notifying you of any adverse benefit determination. Medicaid and NC Health Choice members have a right to appeal adverse benefit determinations to Alliance Health. You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our decisions on an appeal, they can ask the NC Office of Administrative Hearings for a State Fair Hearing.

When you ask for an appeal, Alliance Health has 30 days to give you an answer. You can ask questions and give any updates (including new medical documents from your providers) that you think will help us approve your request. You may do that in person, in writing, or by phone.

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider, or a lawyer to help you. You can call Alliance Health at 919-651-8545 if you need help with your appeal request. It’s easy to ask for an appeal by using one of the options below:

• MAIL: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 60 days after the date on the notice.
• FAX: Fill out, sign, and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax number listed on the form. We must receive your form no later than 60 days after the date on the notice.
• BY PHONE: Call 919-651-8545 and ask for an appeal. When you appeal, you and any person you have chosen to help you can see the health records and criteria Alliance Health used to make the decision. If you choose to have someone help you, you must give them permission.

You can also contact the NC Medicaid Ombudsman at 1-877-201-3750 or go to the Ombudsman website to get more information about your options.

You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health or to your ability to attain, maintain or regain your good health. This faster review is called an expedited appeal.

You and your provider can ask for an expedited appeal by calling us at 919-651-8545.

You can ask for an expedited appeal by phone, by mail, or by fax. There are instructions on your Appeal Request Form that will tell you how to ask for an expedited appeal.

If your provider asks us for an expedited appeal, we will give a decision no later than 72 hours after we get the request for an expedited appeal. We will call you and your provider as soon as there is a decision. We will send you and your provider written notice of our decision within 72 hours from the day we received the expedited appeal request.

Alliance Health will review all member requests for expedited appeals. If your request for an expedited appeal is denied, we will call you during our business hours promptly following our decision. We also will tell you and the provider in writing if your request for an expedited appeal is denied. We will tell you the reason for the decision. Alliance Health will mail you a written notice within 2 calendar days. If you do not agree with our decision to deny an expedited appeal request, you may file a grievance with us. For more information on grievances, see your Member Handbook.

When we deny a member’s request for an expedited appeal, there is no need to make another appeal request. The appeal will be decided within 30 days of your request. In all cases we will review appeals as fast as a member’s medical condition requires.

If we have all the information we need, we will make a decision on your appeal within 30 days from the day we get your appeal request. We will mail you a letter to tell you about our decision. If we need more information to decide about your appeal, we:

• Write to you and tell you what information is needed
• Explain why the delay is in your best interest
• May take an additional 14 days to decide your appeal if you request it or if there is a need for additional information and the delay is in your best interest

If you need more time to gather records and updates from your provider, just ask. You or a helper you name may ask us to delay your case until you are ready. Ask for an extension by calling Member and Recipient Services at 800-510-9132 or writing to:

Alliance Health
5200 W. Paramount Parkway, Suite 200
Morrisville, NC 27560

When we decide on your appeal, we will send you a letter. This letter is called a “Notice of Decision.” If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within 120 days from the date on the Notice of Decision.

If you do not agree with Alliance Health’s decision on your appeal, you can ask for a State Fair Hearing. In North Carolina, State Fair Hearings include an offer of a free and voluntary mediation session. This meeting is held before your State Fair Hearing date.

Free and Voluntary Mediations

When you ask for a State Fair Hearing, you will get a phone call from The Mediation Network of North Carolina. The Mediation Network will call you within 5 business days after you request a State Fair Hearing. During this call, you will be offered a mediation meeting. The state offers this free meeting to help resolve your disagreement quickly. These meetings are held by phone.

You do not have to accept this meeting. You can ask to schedule just your State Fair Hearing. When you do accept, a Mediation Network counselor will lead your meeting. This person does not take sides. A member of the Alliance Health review team will also attend. If the meeting does not help with your disagreement, you will have a State Fair Hearing.

State Fair Hearings

State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). An administrative law judge will review your request along with new information you may have. The judge will make a decision on your service request. You can give any updates and facts you need to at this hearing. A member of the Alliance Health review team will attend. You may ask questions about Alliance’s decision. The judge in your State Fair Hearing is not a part of Alliance Health in any way.

It is easy to ask for a State Fair Hearing. Use one of the options below:

• MAIL: Fill out and sign the State Fair Hearing Request Form that comes with your notice. Mail it to the addresses listed on the form.
• FAX: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. You will find the fax numbers you need listed on the form.
• BY PHONE: Call OAH at 984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call.

If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court where you live. You have 30 days from the day you get your decision from your State Fair Hearing to appeal to the Superior Court.

State Fair Hearings and Disenrollment Decisions

If you disagree about a decision to change your health plan, you can ask for a State Fair Hearing. The process to ask for a State Fair Hearing for disenrollment decisions is different than the process to ask for a State Fair Hearing when Alliance Health limits or denies a service that you requested. For more information about requesting a State Fair Hearing for disenrollment decisions, see your Member Handbook.

Sometimes Alliance Health’s decision reduces or stops a health care service you are already getting. You can ask to continue this service without changes until your appeal is finished. You can also ask the person helping you with your appeal to make that request for you. Your provider cannot ask for your services to continue during an appeal.

The rules in this section are the same for Appeals and State Fair Hearings. There are special rules about continuing your service during your appeal. Please read this section carefully!

You will get a notice if Alliance Health is going to reduce or stop a service you are receiving. You have 10 calendar days from the date we send the letter to ask for your services to continue. The notice you get will tell you the exact date. The notice will also tell you how to ask for your services to continue while you appeal.

If you ask for your services to continue, Alliance Health will continue your services from the day you ask for them to continue until the day get your appeal decision. You or your authorized representative may contact Member and Recipient Services at 800-510-9132 or contact the Appeals Coordinator on your adverse benefit determination letter to ask for your service to continue until you get a decision on your appeal.

Your appeal might not change the decision the health plan made about your services. When this happens, Medicaid allows Alliance Health to bill you for services we paid for during your appeal. We must get approval from NC Medicaid before we can bill you for services we paid for during your appeal. If Alliance chooses to seek to recover the cost of services provided to you during the appeal process, Alliance will develop a member hardship exemption process and obtain prior approval from NCDHHS for each instance Alliance seeks to recover.

If you decide to leave Alliance Health, your appeal may be impacted by this transition. Please see below for additional information to learn how we will process appeals at transition. If you will be transitioning out of our health plan soon and have an appeal with us, please contact Member and Recipient Services at 800-510-9132 for additional information.

If you transfer to another Medicaid health plan in the middle of an appeal, you should work with your provider to submit the request to your new Medicaid health plan. They may have different services than Alliance offers and your provider should be able to assist you in identifying the best services to meet your needs. For any service that Alliance has authorized, we will transmit a copy of that authorization to your new Medicaid health plan as a part of your transition.