Participant Appeal Procedure
What do I do if I am denied a service and have not been able to come to an agreement?
You have the right to file an appeal based on any decision by your Interdisciplinary Team to deny, reduce, or refuse to pay for a particular service that
you wish to receive. If you wish to file an appeal, you must make you request for the appeal within thirty (30) days of AllCARE for Seniors’ decision to
deny, reduce, or refuse to pay for a particular service. You may request an appeal at any time by simply telling an AllCARE for Seniors employee that you
would like to file an appeal, telephoning the AllCARE for Seniors Center at (276) 964-7176 or Toll Free at (866) 828-7723, or writing a letter to AllCARE
for Seniors and mailing it to:
AllCARE for Seniors
P.O. Box 765
Cedar Bluff, VA 24609
AllCARE for Seniors will respond to and resolve your appeal as quickly as your health condition requires but no later than thirty (30) calendar days after your appeal is received.
If you believe that your life or health will be in immediate danger if you do not receive the service, you may request an expedited appeal. If you file an expedited appeal, the AllCARE for Seniors Nurse Manager and your doctor will review your case immediately and respond back to you within three days. AllCARE for Seniors may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons:
- The participant requests the extensiom.
- AllCARE for Seniors justifies to Virginia DMAS the need for additional information and how the delay is in the interest of the participant.
You may file your appeal directly to the Virginia Department of Medical Assistance as well by calling (804) 371-8488 or by writing a letter. Please include
a copy of the notice or letter about the action you are appealing. You may also complete an Appeal Request Form. Forms are available on the internet at
www.dmas.virginia.gov, at your local department of social services, or by calling (804) 371-8488. Sign the appeal request and mail it to:
Virginia Department of Medical Assistance Services
600 East Broad Street
Richmond, Virginia 23219
Appeal requests may also be faxed to (804) 371-8491
If you file an appeal, AllCARE for Seniors will continue to furnish the disputed service(s) until a decision is made regarding your appeal request if the following conditions are met:
- AllCARE for Seniors proposes to terminate or reduce services currently being furnished to you.
- You decide to continue receiving the service with the understanding that you may have to pay for the service if AllCARE for Seniors decides not to reverse their decision.
AllCARE for Seniors will continue to furnish you all other required services during the appeals process. There will be no discrimination by AllCARE for Seniors against you because you filed an appeal. You will also be given a written description of the formal appeal process that explains how long it will take for us to make a decision on your appeal and what factors will be considered in our decision. You will also have a chance to discuss your appeal with us.
Your appeal will be treated by all AllCARE for Seniors employees in a confidential manner at all times.
You will never be discriminated against for filing an appeal.
In addition to appealing directly to AllCARE for Seniors you have the right to file an appeal directly with Medicaid or Medicare, depending on your eligibility.
If you are a client of the Medicaid Program, you have the right to file an appeal, directly to DMAS, for any decision related to denial, reduction, notice to terminate, suspension or refusal to pay for any service. You do not have to exhaust internal AllCARE for Seniors review procedures before exercising your right to appeal directly to DMAS. You or your authorized representative must send a written appeal request within thirty (30) days of receipt of the IDT adverse decision. Your appeal must be postmarked or received by DMAS within thirty (30) days of the adverse decision. If you file an appeal within this timeframe, the disputed service may continue during the appeal process. However, if this action is upheld by the Appeals Division, you may be required to reimburse AllCARE for Seniors for the cost of the disputed services paid on your behalf during the appeal period.
You may write a letter or complete an Appeal Request Form. Forms are available on the internet at www.dmas.virginia.gov, at your local department of social services, at your PACE Center, or by calling DMAS at (804) 371-8488.
Please include a copy of the written adverse decision. Sign the appeal request and mail it to:
Department of Medical Assistance Services
600 East Broad Street
Richmond, Virginia, 23219.
Appeal requests may also be faxed to: (804) 371-8491.
If you are a Medicare recipient you may file your appeal through what is known as the Medicare managed care appeals process. AllCARE for Seniors staff can help you walk through the process for doing this.