Filing an Appeal
The appeal process allows the member, the member’s authorized representative (family member, etc.), or a provider acting on the member’s behalf with the member’s written or consent, to file an appeal.
The appeal process allows the member to request NH Healthy Families to review a decision that has been made. An appeal is the request for review of an action or decision made by NH Healthy Families that is not in the member’s favor. The member will be allowed 60 calendar days from the date of adverse action to file an appeal. You have the right to choose someone to represent you during your Appeal with NH Healthy Families. To designate a representative, please compete the Authorized Representative Form. Notice will be issued that denies or limits the authorization of a requested service, including:
- The type or level of service;
- The reduction, suspension, or termination of a previously authorized service;
- The denial, in whole or part of payment for a service except when payment for a service is solely because the claim does not meet the definition of a “clean claim”
- Untimely service authorizations;
- The failure to render a decision within the required timeframes; or
- The denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the NH Healthy Families network.
Request for an appeal: The appeal may be requested in writing or orally.
Timeframe for resolution an appeal: Standard appeals must be resolved within 30 days of receipt of the appeal, with a 14 day extension possible if additional information is required or if the member requests it. Members may request that NH Healthy Families review the Notice of Adverse Action to verify if the right decision has been made.
Request for an expedited appeal: Expedited appeals may be filed when either NH Healthy Families or the member’s provider determines that the time taken for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.
Timeframe for resolution of an expedited appeal:
- Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal.
- NH Healthy Families may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if NH Healthy Families justifies a need for additional information and how the extension is in the member’s interest. For any extension not requested by the member, NH Healthy Families shall provide written notice to the member of the reason for the delay.
- NH Healthy Families shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.
In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals. The member has a right to file a grievance regarding the Plan’s denial of a request for an expedited resolution. The Plan will inform the member of their right to file a grievance in this instance.