${Capital Complaint_or_Grievance} and appeals

You can have someone else file a ${small complaint_or_grievance} or appeal for you. They can also act for you in a state fair hearing. This person is your member representative. They may be:

• Your provider
• Your family member 
• Your friend
• Your legal guardian
• Your attorney
• Another person

You have to give written permission to the person, allowing them to act for you. 

• For ${small complaint_or_grievance}s, you can write a letter. 
• For appeals, you can write a letter or fill out the [name of form] form (PDF). If you need the form, call us at ${member_services_phone}.
• [Use this bullet to describe what to do if you want someone else to act for you in a state fair hearing. Example only: For state fair hearings, you can write a letter to the Division of Administrative Law and include it with your state fair hearing request.]

If you write a letter, tell us that you want someone else to act for you to file a ${small complaint_or_grievance} or appeal. Be sure to include:

• Your name
• Your member ID number from your ID card
• The name of the person you want to represent you
• What your grievance or appeal is about

Then, sign the letter and send it to:

[Insert specific complaints and appeals plan address — typically not the general plan address]

Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.

When we get the letter, the person you chose can act for you. If someone else files a ${small complaint_or_grievance} or appeal for you, you can’t file one yourself about the same item.

Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, those services will continue automatically during your appeal, as long as:

• You file your appeal on or before the last day of the original authorized period, or within [X] days of our decision letter, whichever is later
• The appeal involves stopping, holding or reducing a treatment that was approved before
• The authorization hasn’t expired
• An authorized provider ordered the services in question 

Your services will continue until one of these things happens:

• You withdraw the appeal.
• The original authorization period for your services has been met.
• [XX] days have passed since we mailed you our appeal decision.
  

This applies unless you have asked for a state fair hearing with continuation of services. Read more about this topic under the “State fair hearing” tab.

The appeal decision

• If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
• If the appeal decision is in your favor: We’ll provide the disputed services within [XX] hours from the date of the appeal decision if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.

You can speed up your appeal if waiting up to [XX] calendar days is harmful to your health. This is an expedited or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within [XX] hours. We can increase the review period up to [XX] days if you ask for an extension or we need more info and the delay is in your interest.

You can also ask for a quick decision in situations that involve:

• Urgent or emergency care
• A new or continued hospital stay
• Availability of care
• Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility

If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within [XX] days. Then, we’ll process your appeal normally, in the usual timeframe ([XX] days). 

[Highly individualized based on plan. Let the legacy page and plan SMEs be your guide, but here are two very different examples:

https://prevwww.aetnabetterhealth.com/texas/medicaid-complaint-appeal.html

https://prevwww.aetnabetterhealth.com/newjersey/medicaid-grievance-appeal.html]

You can ask for a state fair hearing from the [state governing body name] if you don’t agree with our appeal decision. The state’s rules say you must wait for your internal appeal to be complete first.

You must also ask for a state fair hearing in writing within [XX] days of the date of the appeal decision letter from your internal appeal.

You have many options to ask for a state fair hearing. Just contact the [state governing body name]:

Online

Complete the [name of form] form. 

By mail

You can also mail the [name of form] form. Print the form, complete it and mail it to:

By fax

You can also fax the [name of form] form. Print the form, complete it and fax it to [XXX-XXX-XXXX].

By phone

Just call [1-XXX-XXX-XXXX]. 

[COPY: A common topic. Adapt as needed or delete based on plan details.]

Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a state fair hearing, you have the right to ask that your services continue while your appeal is pending. Check the box on the [name of form] form that you want to continue services.

[URL or PDF asset for online recipient appeal request form]

[Insert state-specific resource]

You must ask for your services to continue in writing within [XX] days of the date of our appeal decision letter. Your services will continue until one of these things happens:

• You withdraw the appeal.
• The original authorization period for your services has ended.
• The State Fair Hearing Officer denies your request.

If you miss the [XX]-day deadline, we’ll reduce, hold or stop your services by the effective date.

The state fair hearing decision

• If the state fair hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.
• If the state fair hearing decision is in your favor (reverses our decision): We’ll make sure you get the disputed services right away — as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.