<Insert address and phone Send you a letter with our number> reason and tell you about your rights if you disagree. If you do not You can: We will: agree with a Write us, or call us and Send you a letter within 5 decision we follow up in writing, within 60 business days to tell you we made about days of our decision about received your appeal. your services, your services. Help you complete any you can ask for Ask for your services to forms. an Appeal continue within 10 days of Review your appeal and receiving our letter, if send you a letter within 30 needed. Some rules may days to answer you. apply. <Insert address and phone number> If you think You can: We will: waiting for 30 Write us or call us within 60 Give you an answer within days will put days of our decision about 48 hours after we receive your health in your services. your request. danger, you Call you the same day if we can ask for an <Insert address and phone do not agree that you need a Expedited or number> fast appeal, and send you a Appeal “Fast” letter within 2 days. If you do not You can: We will: agree with our Write to the Agency for Provide you with appeal Health Care Administration transportation to the decision, you Office of Fair Hearings. Medicaid Fair Hearing, if can ask for a needed. Ask us for a copy of your Medicaid Fair medical record. Restart your services if the Hearing State agrees with you. Ask for your services to continue within 10 days of If you continued your services, we receiving our letter, if may ask you to pay for the services needed. Some rules may if the final decision is not in your apply. favor. **You must finish the appeal process before you can have a Medicaid Fair Hearing. Fast Plan Appeal
<Insert address and phone number> Send you a letter with our reason and tell you about your rights if you disagree. If you do not agree with a decision we made about your services, you can ask for an Appeal You can: Write us, or call us and follow up in writing, within 60 days of our decision about your services. Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply. <Insert address and phone number> We will: Send you a letter within 5 business days to tell you we received your appeal. Help you complete any forms. Review your appeal and send you a letter within 30 days to answer you. If you think waiting for 30 days will put your health in danger, you can ask for an Expedited or “Fast” Appeal You can: Write us or call us within 60 days of our decision about your services. <Insert address and phone number> We will: Give you an answer within 48 hours after we receive your request. Call you the same day if we do not agree that you need a fast appeal, and send you a letter within 2 days. If you do not agree with our appeal decision, you can ask for a Medicaid Fair Hearing You can: Write to the Agency for Health Care Administration Office of Fair Hearings. Ask us for a copy of your medical record. Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply. **You must finish the appeal process before you can have a Medicaid Fair Hearing. We will: Provide you with transportation to the Medicaid Fair Hearing, if needed. Restart your services if the State agrees with you. If you continued your services, we may ask you to pay for the services if the final decision is not in your favor. Fast Plan Appeal
Enrollee_Handbook_Template_For_MMA-and-LTC.docx