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.
- 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.