Denial of HUSKY A Services

What You Should Know About the Appeal/Administrative Hearing Process

You have received a letter from your health plan called a Notice of Action (NOA). This letter tells you that your HUSKY A health plan has denied a service that you or your health care provider asked for. This flyer will help you understand the Notice of Action and what you can do about it.

What is Notice of Action?

A Notice of Action (NOA) is a letter that your health plan must send to you when a requested service has been denied. A Notice of Action letter tells you:

· What service has been denied by your health plan;

· What reason the health plan has for denying the service; and

· How to appeal (challenge) the decision to deny a service.

If you do not agree with the health plan's decision to deny a service, what can you do?

You can appeal (challenge) the decision. To appeal means to ask the people who made the decision to change their minds, after you have given reasons why you think they should.

To start the appeal process, fill out the Appeal and Administrative Hearing Request Form included in the envelope with your Notice of Action. Send the completed Appeal and Administrative Hearing Request form to the Department of Social Services (DSS) within 60 days of the date on your NOA.

Please remember to fill in all the blanks on the form, including:

Also, turn the page over to complete the back. If you need help with this form, call your health plan. The health plan's phone number is on the bottom of the NOA. Or you can call the HUSKY Infoline at 1-800-434-7869. Press Option 3.

IMPORTANT: If you wait longer than 60 days to send in the form, you will lose your right to appeal the decision.

What happens after you send in the Appeal and Administrative Hearing Request Form?

· First, your health plan will review its decision to deny services. This is called an Appeal.

· Second, an administrative hearing (formerly called Fair Hearing) will be scheduled with DSS. You will be told the time and place of the scheduled hearing.

When will an Administrative Hearing take place?

An administrative hearing will automatically be scheduled when you send in an Appeal and Administrative Request Form. An administrative hearing will take place:

· If you are not happy with your health plan's appeal decision, or

· If the health plan does not make a decision about your appeal before the date of the scheduled administrative hearing.

What happens at the Administrative Hearing?

You will meet with an Administrative Hearing Officer from DSS and with a representative from your health plan. You can explain why you do not agree with the health plan's decision. You may take a friend, relative, or other person with you for support. You may also present additional information, documentation or medical records to support your argument. You can also have a lawyer represent you at the hearing. Free legal help may be available from your local Legal Service Office. Call 1-800-453-3320 for more information.

The Hearing Office at DSS must schedule the administrative hearing within 30 days of receiving your appeal form. The Hearing Officer at DSS must make the Administrative Hearing decision no later than 90 days from the time you sent in the Appeal and Administrative Hearing Request Form.

What is an expedited appeal and hearing?

If the regular timeframes for an appeal and hearing would put your life or health at serious risk, you or your care provider can ask for an expedited review of your request. The Notice of Action explains the expedited appeal and hearing process.

If you have any questions about the Appeal and Administrative Hearing Process:

· First, call your health plan - read your Notice of Action letter for contact information;

· You can also call the HUSKY Infoline for help. Call 1-800-434-7869 (TDD available).