Service Appeals

If you are denied services, you have the right to appeal that decision. By submitting an appeal request, your decision will be given second consideration by Sandhills Center.

You have the right to appeal:

• Service denials
• Service reductions
• Limited authorization periods
• Type or level of service
• Suspensions or terminations of a previously authorized service

How do I Appeal a Medicaid Decision?

If you get a Letter of Notification from Sandhills Center saying that some or all of your Medicaid services have been reduced, suspended, terminated or denied, you can appeal this decision.

If you appeal within the timelines listed in your letter, your services may continue throughout the appeal unless the appeal is for denial of a new request for services. Your first step is to file a Reconsideration Request. The process for filing the Reconsideration Request will be included in the Letter of Notification.

It is very important for you to exactly follow all procedures stated in your notices and letters. If you have questions, call 1-800-256-2452, and ask for the Utilization Management Department, which handles appeals over suspension, termination, or denial of services.

Denials

Your services may be denied if the criteria are not met to support a new authorization request for a service. You will receive a letter by U.S. mail explaining this decision and how to request a Reconsideration. During the appeal period, Sandhills Center will not provide the denied service.

Reductions, Suspensions or Terminations

Services you currently are receiving may be reduced, suspended or terminated based on several different factors: Not following clinical guidelines or not continuing to meet medical necessity for the frequency, amount or duration of a service.

You will receive a letter by U.S. mail at least 10 days before the change occurs explaining how to request a Reconsideration. If you request a Reconsideration by the deadline stated in the letter, your services may continue through the end of your original authorization.

Step One: The Reconsideration Request

A Reconsideration is the first step appealing your decision before proceeding with the Appeals Process through the Office of Administrative Hearings (OAH). A health care professional who has appropriate clinical expertise in treating your condition or disorder decides Reconsiderations. It can take up to 30 days for a Reconsideration decision to be made. You or your provider may request an Expedited Reconsideration (which takes 72 hours, instead) if the standard review length could jeopardize your health and safety. If your provider or another representative requests a Reconsideration, you may be asked to sign a consent to release information.

To File a Reconsideration Request

To request a Reconsideration, complete and return the Reconsideration Request by fax, mail, verbally over the phone, or bring the form to Sandhills Center. You have 60 days from the date of notification to make a Request for Reconsideration. During Reconsideration, you and/or anyone you choose may represent you. If someone represents you, you will be asked to sign a consent to release information.

You have the right to review any information that was utilized as part of the Reconsideration process. You may also submit any additional information you feel supports the level of service(s) being requested.

If you disagree with the Reconsideration decision, you may submit your appeal to the North Carolina Office of Administrative Hearings. This form is enclosed with the Reconsideration decision and will start the Appeals Process.

Submit Your Reconsideration Request:

• By phone: 1-800-256-2452
• By fax: (336) 389-6543
• By mail or in person: Sandhills Center, Appeals Coordinator, 185 Grant St., West End NC 27376

What is the Appeals Hearing Process?

You must file your appeal with the North Carolina Office of Administrative Hearings (OAH) within 120 days from the date of the Reconsideration decision. After filing your appeal, you will be offered the opportunity to have your case mediated. If you accept mediation, it must be completed within 25 days of your request.

If you either decline mediation or mediation is unsuccessful, your appeal will proceed to a hearing. After the hearing, an administrative law judge will prepare a written final decision that includes findings of fact and conclusions of law. Upon notification of the final decision, either you or Sandhills Center will have the right to seek judicial review of the decision.

Am I Responsible For Services Furnished While the Appeal Is Pending?

If the North Carolina Department of Health and Human Services  final decision is not in your favor, then Sandhills Center has the right to recover the cost of the services you received during the Appeal process.

Important Timelines to Remember

• If a Medicaid service is reduced, suspended or terminated, you will be notified 10 days in advance. If you appeal within 10 days of the notification, you may continue receiving services.
• If a Medicaid service is denied, you will be notified when the decision is made.
• You have 60 days from the date of the Notice of Decision letter to request a Reconsideration of the decision.
• Sandhills Center will notify you within 30 days of the Reconsideration decision.

Non-Medicaid Service Decisions

If you receive a letter from Sandhills Center stating that all or some of your non-Medicaid services have been reduced, suspended, terminated or denied, you may appeal the decision. All standard appeals are processed, completed, and communicated in writing within 7 business days once the request is received. After Utilization Management receives the appeal request, they have 7 business days to conduct an appeal and notify the member of the decision in writing.

Once the member is notified of the decision, they may submit a written request to appeal within 15 days. Utilization Management may assist a member in filing a written appeal.

Instructions for requesting an appeal (including where and to whom to send it) are included in peer review notification of non-certification. The Notification Letter will also include the timeframes for requesting an appeal.

After Utilization Management receives the appeal request, they have 7 business days to conduct an appeal and notify the member of the decision in writing.

Members may appeal upheld denials externally to the State Division of Mental Health, Developmental Disabilities and Substance Abuse Services Non-Medicaid Appeals Panel. This is a panel of individuals designated by the NC MH/DD/SAS to review the Non-Medicaid Appeal Requests to DHHS. The panel will issue their recommendations to the member and to Sandhills Center within 60 days. Sandhills Center will then issue the Final Decision in writing within 10 days of receiving the panel's recommendations.

An enrollee or guardian may submit additional information that they feel supports the request. All information should be faxed or mailed to the Sandhills Center Utilization Management Department with the Appeal Request Form. An enrollee/guardian may speak for him/herself or be represented by an attorney, representative or other spokesperson.