Medical Appeals (Part C)

Medical appeals (Part C) – What is an appeal?

An appeal is a way for you to ask us to change a decision we made about your medical coverage. Making an appeal means trying to get the medical care coverage you want.

Making an appeal

You must make your appeal request within 60 calendar days from the date on the written notice we sent to you. You will get an answer within 15 calendar days. We may extend this timeframe by additional 14 calendar days if it is in your best interest. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Fast (expedited) appeals will be processed within 72 hours.

If you would like to file an appeal, 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.

You may also send your written appeal by mail or fax:

  • Fax: 1-844-273-2671
  • Mail:
    Absolute Total Care (Medicare-Medicaid Plan)
    Attn: Medicare Appeals and Grievances
    7700 Forsyth Blvd
    St Louis, MO 63105

Please include the following:

  • Your name;
  • Your address and phone number;
  • 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.

If our decision is not in your favor, you may request a second level appeal within 30 calendar days after the date of our written notice.

You must appeal benefits only offered by Medicaid within 10 calendar days after you receive the Notice Adverse Benefit Determination or the planned effective date of the action, whichever is later if you want to continue getting these services.

Please keep one copy of the fair hearing request for your information.

How do non-contracted providers file a claim appeal?  

In accordance with the requirements established by the Centers for Medicare & Medicaid Services (CMS), non-contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which we have denied payment.

  • All requests for payment appeals must include a completed and signed “Waiver of Liability” (WOL) statement.
  • The appeals process cannot begin until a completed and signed WOL is received.
  • Requests for appeals that do not include a WOL, or for which a WOL is not received within the required timeframes, will be issued a Notice of Dismissal of Appeal Request.
  • Requests for payment appeals must be filed within 60 calendar days of the explanation of payment (EOP).
  • A copy of the EOP and any other supporting documentation (such as medical records when applicable) must be submitted with the appeal request.

We will make a decision regarding the appeal within 60 calendar days from the date the appeal request was received with the completed Waiver of Liability.

Non-Contracted Provider Appeal Requests should be submitted, with the completed WOL, to the following address:

Absolute Total Care (Medicare-Medicaid Plan)
Grievance and Appeals - Medicare Operations
P.O. Box 4000
Farmington, MO 63640-3822

Last Updated: 09/30/2017
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