Appeals and Grievances

Important information about your appeals rights

There are two kinds of ppeals:

Standard appeal: You have the right to appeal if you don’t agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 15 calendar days after we get your 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’re taking extra time and will explain why more time is needed.  If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.

Fast appeal: You will get an answer within 72 hours after we get your fast appeal. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 15 calendar days for a decision.

We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal.  If we don’t give you a fast appeal, we’ll give you an answer within 15 calendar days.

How to ask for an appeal with Absolute Total Care

Step 1: You, your authorized representative, or your doctor must ask us for an appeal.  Your written request must include:

  • Your name;
  • Your address;
  • Your Absolute Total Care ID number;
  • Your reasons for appealing; and
  • Your medical records, doctor’s letter, or other information that proves why you need the item or service. Call your doctor if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision, at no cost to you.

Step 2: Mail, fax, hand-deliver your appeal, or call us.

For a standard appeal:

Mail:
Absolute Total Care (Medicare-Medicaid Plan)
Attn: Appeals and Grievances
7700 Forsyth Blvd.
St. Louis, MO 63105
Telephone: 1-855-735-4398 (TTY: 711)
Fax: 1-844-273-2671

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If you ask for a standard appeal by phone, we will send you a letter outlining what you told us.

For a fast appeal:

Telephone: 1-855-735-4398 (TTY: 711)
Fax:  1-844-273-2671

What happens next?  

If you ask for an appeal and we continue to deny your request for a service or payment of a Medicare-covered service, we will send you a written decision and forward your case to the Medicare Independent Review Entity (IRE). If the IRE denies your request, the written decision will explain if you have additional appeal rights.

You may also have the right to request a State Fair Hearing:

You have the right to ask for a State Fair Hearing if we denied your South Carolina Healthy Connections Medicaid service. You may name someone to represent you. A doctor or other medical provider may also represent you. You or your representative must ask for the State Fair Hearing within 120 days of the date on the Absolute Total Care letter with the decision. If you do not ask for a State Fair Hearing within 120 days, you may lose your right to a fair hearing.

You have the right to ask for a State Fair Hearing with the South Carolina Department of Health and Human Services (SCDHHS), Division of Appeals and Hearings. Anytime you receive a notice of denial about a Healthy Connections Medicaid service, the letter will tell you how you can file an appeal with Absolute Total Care or ask for a State Fair Hearing with SCDHHS. Fill out the State Fair Hearing form and mail it to SCDHHS - Division of Appeals and Hearings. You can also fax your request to 1-803-255-8206. You can request a hearing within 120 calendar days of the date on the initial denial letter/state hearing rights notice.

If the decision of the independent reviewer is not completely in your favor, you may request a State Fair Hearing in addition to any other appeal rights.

Step 1: You or your authorized representative must ask for a State Fair Hearing (in writing) within 120 days of the date of the notice of denial.  If you want your provider to request the State Fair Hearing request for you, you must give written permission (complete an Authorized Representative Form) for the doctor to do so.

Your written request must include:

  • Your name;
  • Your address;
  • Absolute Total Care ID number;
  • Your reasons for appealing; and
  • Your medical records, doctor’s letter, or other information that proves why you need the item or service. Call your doctor if you need this information.

If you want to ask for a State Fair Hearing related to a standard Medicaid item or service:

Step 2: Send your request to:

Mail:
South Carolina Department of Health and Human Services
Division of Appeals and Hearings (Suite 901)
P.O. Box 8206
Columbia, SC 29202-8206
Telephone: 1-803-898-2600
Fax: 1-803-255-8206

How to get a total number of grievances, appeals, and exceptions filed with Absolute Total Care

To obtain a total number of grievances, appeals, and exceptions, please call Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

What is a grievance?

A grievance is a complaint about anything other than benefits, coverage, or payment. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You would also file a grievance if you did not think we responded quickly enough to your request for coverage determination or organization determination, or to your appeal. Grievances are responded to within 30 calendar days.

Filing a grievance

You or your authorized representative can file a grievance by:

  • Calling Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday.  After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

OR

  • Writing us a letter. Include your name, Absolute Total Care ID number, address and telephone number and the reason why you are not happy, and mail it to:

    Absolute Total Care (Medicare-Medicaid Plan) 
    Attn: Medicare Operations
    7700 Forsyth Blvd
    St Louis, MO 63105

OR

  • Calling Medicare 1-800-Medicare. Calls to this number are free, 24 hours a day, seven days a week. TTY users call 1-877-486-2048.

OR

 

Last Updated: 11/14/2017
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