CurrentOptumPolicy N/A

Appeals and member options for behavioral health decisions

Explains member options to appeal or request a state fair hearing for behavioral health coverage decisions and provides contact routes (Medica Behavioral Health / Medica Customer Service). Affects members who received an adverse behavioral health decision.

Policy Summary

PayerOptum

PolicyAppeals and member options for behavioral health decisions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf you disagree with this decision, appeal to Medica Behavioral Health or request a state fair hearing; contact Medica Customer Service for assistance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2options available

90dappeal to Medica within

30dstate fair hearing request

10dservices continue after filing

No costhearing cost to member

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Appeal criteria and constraints

Member actions and constraints when appealing behavioral health decisions

Members may appeal coverage decisions to Medica Behavioral Health or request a state fair hearing.

Appeals must follow specified timing and eligibility rules; some appeals may be limited if the member is not eligible at the time of the decision.

Members may have a relative, friend, designated provider, or legal representative help with the appeal process as described in the notice.

Appeals — operational guidance (partial)

Appeals filing instructions and available assistance (partial content).

To file an appeal, contact Medica Behavioral Health as instructed on the notice; you may call Medica Customer Service for assistance.

ONE of: A state program (for example, county-managed care or Department of Human Services) may be able to help you file an appeal to Medica Behavioral Health.

If you disagree with the decision you can submit an appeal by the methods specified on the notice; member eligibility may affect appealability.

Appeals and state fair hearing

Guidance on appeal rights and next steps

Members can appeal to Medica Behavioral Health within 90 days after the date of the notice.

WHO CAN HELP: If a member cannot appeal by phone or in writing, a relative, guardian, or county-managed care/human services office may help and can contact Medica Behavioral Health on their behalf.

Instructions are provided in the section titled 'REQUEST A STATE FAIR HEARING' for requesting a state fair hearing when appropriate.

Continuation and hearing procedures

Rules about continuation of health care services during appeals and state fair hearings, necessary documentation, and timelines.

Members may request a state fair hearing; the notice explains how to do so.

If you ask for continuation of services during an appeal or state fair hearing, the requested service must be continued and be made available within 10 days of the request if the provider agrees.

If services were continued and later found not to be covered because they were not medically necessary, different rules about cost or coverage may apply as described in the notice.

Providers must agree that the service should continue for continuation of care to occur; providers can continue services during the appeal/hearing as instructed.

Medical records and other documents may be requested or used during the appeal or state fair hearing; the state may request information at any time during the process.

What Providers / Members Should Do

Note

Appeal options

If you disagree with this decision, you have two options: you may file an appeal with Medica Behavioral Health or request a state fair hearing. You can also get help understanding the notice from your county-managed care or human services office.

You may file an appeal with Medica Behavioral Health if you disagree with the decision about services.
To file an appeal, contact Medica Behavioral Health. Members, providers, or a member’s authorized representative may file an appeal on the member’s behalf.
Assistance is available — your county-managed care or human services office may also be able to help you file an appeal or request a state fair hearing.

Note

How to file an appeal / Who may contact

Who may contact and how to file: You, your authorized representative, or the provider may contact Medica Behavioral Health to file an appeal. If you need help filing an appeal or requesting a state fair hearing, county-managed care or human services offices can assist.

Members, providers, or an authorized representative may file an appeal on the member’s behalf.
To file, contact Medica Behavioral Health directly by phone or other member services channels.
If you need help, contact your county-managed care or human services office for assistance with filing an appeal or requesting a state fair hearing.

Note

Customer service contact

Customer service contact: Call Medica Customer Service to initiate an appeal or to get help with the process.

Call Medica Customer Service to file an appeal or get assistance.
If you prefer in-person help, contact your county-managed care or human services office; they may be able to assist with appeals or state fair hearing requests.

Prior Authorization

Provider continuation requirement

Provider continuation requirement: The provider must agree that the service should continue. If the provider agrees, services may continue during the appeal or state fair hearing process as instructed.

A provider must agree that the service should continue for continuation during the appeal/hearing.
Providers can continue services during the appeal or hearing process as directed.

Definitions and Key Terms

Adverse behavioral health decision

DefinitionAdverse behavioral health decision = a coverage decision that may trigger appeal rights (denial/modification of behavioral health services).

Formats of noticeMay be communicated by telephone or in writing as stated in the notice text.

ImplicationReceipt of this decision notifies the member of available appeal routes and any service continuation conditions.

State Managed Health Care Programs / Department of Human Services

Stakeholders listedState Managed Health Care Programs and Department of Human Services are referenced as organizations that may assist with appeals.

RolesThese entities can provide advocacy or filing assistance for members pursuing appeals to Medica Behavioral Health.

Contact routeMembers may contact their county-managed care or human services office for help understanding notices and filing appeals.

Appeal assistance / State fair hearing request

Who can requestYou (the member) may appeal to Medica Behavioral Health within 90 days after the date of this notice.

Alternative filersIf you cannot file by phone or in writing, relatives, guardians, or others may help or file on your behalf as described in the notice.

State fair hearingInstructions and heading are provided for how to request a state fair hearing (section titled 'REQUEST A STATE FAIR HEARING').

Continuation of services during appeal/hearing

Continuation eligibilityServices can continue during an appeal or state fair hearing only if requested and if the provider agrees that the service should continue.

Provider action requiredProvider must agree the service should continue; provider may continue services during the appeal/hearing as instructed.

Timing for continuationIf continuation is requested and granted, services must be continued within 10 days of the filing/request.

OpenPayer

Appeals and member options for behavioral health decisions

Appeals and Coverage Criteria

Codes

What Providers / Members Should Do

Definitions and Key Terms