You also have a right to appeal. This means you can ask for review of an action or decision about what services you get. You will not lose your benefits if you file an appeal. You may file an appeal if we deny or limit a type of service you ask for. You can appeal if we reduce or stop a service that we approved before. You can also appeal if we don’t pay for any part of a service. There are other actions you may appeal. You will not lose your benefits if you do this. You can express a concern, file a grievance or an appeal. It is the law.
If you or your designated client representative (DCR) asks for an appeal, we will review the decision. Your provider may file an appeal for you or help you with your appeal as your DCR. For a DCR to get your medical records to do this, you or your legal guardian must give written permission to your provider. You will not lose your benefits if you file an appeal.
If you are getting services that we approved before, you may be able to keep getting those services while you appeal. This is only for Health First Colorado (Colorado’s Medicaid program) members. It does not apply for CHP+ members. You can do this if:
- Your appeal was sent to us within the required timeframes by you or your provider;
- A Colorado Access provider has asked that you receive the services;
- The time period that the approval (authorization) of the services has not ended; and
- You specifically ask that services continue.
All of the requirements above must be met for you to keep getting services.
You may have to pay for services that you get during the appeal if you lose. You will not have to pay if you win the appeal. Please let us know when you ask for an appeal if you want to keep getting your services. If you keep getting approved services, they will continue for a certain time.
The services will continue until:
- You take back your appeal;
- A total of 10 days pass after we mail the original notice to you that says we denied your appeal. If you request a State Fair Hearing within those 10 days, your benefits will continue. They will continue until the hearing is over.
- The State Fair Hearing office decides that your appeal is denied.
- The authorization for the services ends.
- You are being discharged from the hospital and don’t feel ready to go.
- Denial of continued services, such as physical therapy, that you feel you still need.
- After we get your phone call or letter, you will get a letter within two business days. This letter will tell you that we got your request for an appeal.
- You or your DCR can tell us in person or in writing why you think we should change our decision or action. You or your DCR can also give us any information that you think would help your appeal. These could be records. You or your DCR can ask questions. You can also ask for the information we used to make our decision. You or your DCR can look at our medical records that have to do with your appeal.
- If you appeal a decision or action about a denial or service change, a doctor will review your medical records. The doctor will also review other information. This doctor will not be the same doctor who made the first decision.
- We will make a decision and notify you within 10 business days from the day we get your request. We will send you a letter that tells you the decision. The letter will also tell you the reason for the decision.
If we need more time, we will send you a letter to let you know. Or, you or your DCR can ask for more time. We can only extend the time up to 14 calendar days.
If the appeal is about a new request for services, you or your DCR must ask for an appeal within 60 calendar days from the date on the letter that says what action we have taken, or plan to take.
- If you appeal an action to lower, change, or stop an authorized service, you must file your appeal on time. On time means on or before the later of the following:
- Within 10 days from the mailing date of the Notice of Action letter.
- The date that the action will start.
- You or your DCR can call our appeals team to start your appeal. Tell them you want to appeal the decision or action. If you call to start your appeal, you or your DCR must send us a letter after the phone call unless they request an expedited resolution. The letter must be signed by you or your DCR. We can help you with the letter, if you need help.
The letter must be sent to:
PO Box 17950
Denver, CO 80217-0950
• You or your DCR can request a “rush” or expedited appeal if you are in the hospital, or feel that waiting for a regular appeal would threaten your life or health. The section called “Expedited (“Rush”) Appeals” tells you more about this type of appeal.
• If you are getting services that we have already approved, you may be able to keep getting those services while you appeal. You may have to pay for those services that you get during the appeal if you lose. You will not have to pay if you win the appeal. If you want to keep getting your services, please let us know when you ask for an appeal.
If you feel that waiting for an appeal would seriously affect your life or health, you may need a fast decision from us. You or your DCR can ask for an expedited “rush” appeal.
For a rush appeal, a decision would be made within 72 hours, instead of 10 business days for a regular appeal. We will make our decision on an expedited appeal within 72 hours. This means that you or your DCR have a short amount of time to look at our records, and a short amount of time to give us information. You can give us information in person or in writing. During this time, your services will stay the same.
If we deny your request for a rush appeal, we will call you as soon as we can to let you know. We will also send you a letter within two business days. Then we will review your appeal the regular way. You will get a letter that tells you the decision of the appeal. It will also tell you the reason.
- A State Fair Hearing means that a state administrative law judge (ALJ) will review our decision or action. You can ask for a State Fair Hearing:
- After you have received a decision from us that you do not agree with,
- If you are not happy with our decision about your appeal. A request for a State Fair Hearing must be in writing:
- If your request is about a treatment that we have not approved before, you or your DCR must make the request within 120 calendar days from the date on the letter that tells you the action that we have taken, or plan to take.
- If your request is about treatment that we have approved before, you or your DCR must make the request within 10 calendar days from the date on the letter that tells you the action that we have taken, or plan to take, or before the effective date of the termination or service change takes place, whichever is later.
If you or your DCR want to ask for a State Fair Hearing, you or your DCR may call or write to:
Office of Administrative Courts
633 Seventeenth Street – Suite 1300
Denver, CO 80202
Phone: 303-866-2000 Fax: 303-866-5909
The Office of Administrative Courts will send you a letter that tells you the process and will set a date for your hearing.
You can talk for yourself at a State Fair Hearing or you can have a DCR talk for you. A DCR can be a lawyer or a relative. It can also be an advocate or someone else. The administrative law judge will review our decision or action. Then they will make a decision. The decision of the judge is final.
If you would like to file an appeal, you must first file it with Colorado Access. If you are not happy with our decision, you can then request a formal hearing. This hearing will take place with an administrative law judge (ALJ). The ALJ contact information is listed above. You must make your request for an ALJ hearing in writing. You must also sign your request.
If you are getting services that we have already approved, you may be able to continue those services while you wait for the judge’s decision. But if you lose at the State Fair Hearing, you may have to pay for services that you get during your appeal. You will not have to pay if you win.
If you want help with any part of the appeals process, please contact us. We can help you with any questions you have. We can also help you file an appeal.