Appeal and Hearing Requests

Appeals

If you do not agree with the decision or action listed in the letter you received, you can contact us within 60 calendar days to ask that we change our decision or action. This is called an appeal. The 60-calendar-day period begins on the day after the mailing date on the letter.

If we are reducing, limiting, suspending, or ending a previously covered service, you have the right to keep getting the service until your appeal is completed. The service must be one that we approved you to get from the provider and the time limit we approved must not have ended. To continue a previously covered service, submit your standard or expedited (fast) appeal request within 15 calendar days from the date of this notice or before the intended effective date of our action, whichever is later.

Unless we tell you a different date, we must give you an answer to your appeal in writing within 15 calendar days from the date you contacted us. If we do not change our decision or action because of your appeal, we will notify you of your right to request a state hearing. You may only request a state hearing after you have gone through the AmeriHealth Caritas Ohio appeal process.

If you want to submit an appeal to AmeriHealth Caritas Ohio over the telephone, please call Member Services at 1-833-764-7700 (TTY 1-833-889-6446), 24 hours a day, seven days a week. If you want to submit an appeal in writing, you can fax it to 1-833-329-2164 or mail it to:

Appeals
AmeriHealth Caritas Ohio
P.O. Box 7346
London, KY 40742-7346

There are two kinds of appeals with AmeriHealth Caritas Ohio:

Standard appeal: We will give you a written decision on a standard appeal within 15 calendar days after we get your written or oral appeal. Our decision might take longer if you ask for an extension, or if we need more information about your case. We will tell you if we are taking extra time and will explain why more time is needed. If we miss the time frame for our written decision, you have the right to immediately file a state hearing.

Expedited (fast) appeal: You can ask for a fast appeal, orally or in writing, if you or your provider believe your health could be seriously harmed by waiting up to 15 days for a decision. If AmeriHealth Caritas Ohio accepts your request for a fast appeal, we will issue our written decision as quickly as your health condition requires, but no later than 72 hours after the date we receive your request (unless it is extended). 

You may have someone file an appeal for you, including your provider. You must give written permission to name your provider or another person to file an appeal for you. Fill out the Personal Representative Request Form (PDF) to give your permission. You will need to fax this form to us at 1-833-329-2164 or mail it to Appeals, AmeriHealth Caritas Ohio, P.O. Box 7346, London, KY 40742-7346. Keep a copy for your records. We do not need written permission from you if your provider is requesting a fast appeal on your behalf.

How to ask for an appeal with AmeriHealth Caritas Ohio:

Your request should include:

  • Your name
  • Address and phone number
  • Member Medicaid ID or plan ID number
  • Reason(s) for appeal
  • Whether you want a standard or fast appeal (for a fast appeal, explain why you need one).
  • Any documents you want us to review, such as medical records, a provider’s letter (such as a supporting statement if you request a fast appeal), or other information that explains why you need the service(s). Call your provider if you need this information. 

We will send you a letter confirming that we received what you sent to us. We recommend keeping a copy of everything you send us for your records. You can ask to receive a copy of the medical records and other documents we use to make our decision at no cost to you. You can also ask for a copy of the guidelines we use to make our decision.

Grievances

If you contact us because you are unhappy with AmeriHealth Caritas Ohio or our providers, this is called a grievance. AmeriHealth Caritas Ohio will give you an answer to your grievance by phone, or by mail if we can’t reach you by phone. We will give you an answer within the following time frames:

  • Two working days for grievances about not being able to get medical care
  • 30 calendar days for all other grievances except grievances about getting a bill for care you have received
  • 60 calendar days for grievances about getting a bill for care you have received

If we need more time to make a decision for either an appeal or a grievance, we will send you a letter telling you that we need to take up to 14 more calendar days. That letter will also explain why we need more time. If you think we need more time to make a decision on your appeal or grievance, you can also ask us to take up to 14 calendar days. 

You also have the right to file a complaint at any time by contacting:

  • Ohio Department of Medicaid
    Bureau of Managed Care Compliance and Oversight
    P.O. Box 182709
    Columbus, Ohio 43218-2709
    1-800-605-3040 or 1-800-324-8680
    TTY: 1-800-292-3572
  • Ohio Department of Insurance
    50 W. Town Street
    3rd Floor, Suite 300
    Columbus, Ohio 43215
    1-800-686-1526

If you are unhappy with the result of your appeal, you can ask for a state hearing.

Members