Grievances and Appeals
We hope our members will always be happy with our providers and with us. If you are not happy, we want to know! Louisiana Healthcare Connections has steps for handling problems you may have. Louisiana Healthcare Connections offers our members the following processes to achieve member satisfaction: Appeals, State Fair Hearing for Appeals, and Member Grievances.
An Appeal is a request to review a service that has been denied, limited, reduced or terminated. Appeals may be filed by a member (parent or guardian of a minor member), a representative named by a member, or a provider acting on behalf of a member. An Appeal gets us to review a denial decision to make sure it was the right decision.
You can appeal decisions that:
- Denies the care requested
- Decreases the amount of care provided
- Ends care that was previously approved
- Denies payment for care you may have to pay for
These types of decisions are called “Adverse Actions”. If any of these actions occur, we will send you a letter explaining what the decision is and why we made that decision. It will also include information about your appeal rights.
You may file an Appeal within 30 days from the date on the Adverse Action letter. You may also request copies of any documentation Louisiana Healthcare Connections used to make the decision about your care or Appeal. You can also request a copy of your member records.
We will not hold it against you or treat you differently in any way if you file an Appeal.
HOW TO FILE AN APPEAL
To file an Appeal by phone, call Member Services at 1-866-595-8133 (TDD/TTY 1-877-285-4514). You can also file an Appeal in person or in writing, at: Louisiana Healthcare Connections, 8585 Archives Avenue, Suite 310, Baton Rouge, LA 70809. Or you can fax your Appeal to 1-877-401-8170. If you’d like, you can use this Grievance and Appeal Form.
If you make your Appeal by phone or in person, you may also send Louisiana Healthcare Connections a letter confirming your Appeal, but it is not required.
Louisiana Healthcare Connections will acknowledge your Appeal within five days of receiving it. We will give you a written decision within 30 days from the date of your Appeal. If more than 30 days is required, we may request an extension from DHH. We will have to tell them why we want the extension and how the extension is in the member’s (your) best interest. You may also request an extension (up to 14 days) if more time is needed. You can request an extension by calling 1-866-595-8133 (TDD/TTY 1-877-285-4514) and asking for the Appeals department.
WHO MAY FILE AN APPEAL?
- You, the member (or parent or guardian of a minor member)
- A person named by you (your representative)
- A provider acting for you
You must give written permission if someone else files an Appeal for you. You can give someone this permission using a Personal Appeal Representative Form. We will mail a copy of this form along with all Adverse Action letters. If you want to allow someone to Appeal on your behalf, a Personal Appeal Representative Form must be sent in with your Appeal before your 30 days are up.
If you need help filing your Appeal, call Member Services at 1-866-595-8133 (TDD/TTY 1-877-285-4514), Monday-Friday, 7:00 a.m. to 7:00 p.m.
CONTINUING TO RECEIVE SERVICES
You may ask to continue receiving care related to your Appeal while we review. You must make this request within 10 days after receiving your Adverse Action letter. IMPORTANT: You may have to pay for this care if the final appeal decision is not in your favor.
FAST APPEAL DECISIONS
If your medical condition is considered urgent, we may be able to make a decision about your appeal much faster. You may need a fast decision if, by not getting the requested services, one of the following is likely to happen:
- You will be at risk of serious health problems, or you may die;
- You will have serious problems with your heart, lungs, or other body parts; or
- You will need to go into a hospital.
Your doctor must agree that you have an urgent need. If you feel you need a fast appeal decision, call 1-866-595-8133 (TDD/TTY 1-877-285-4514) and ask for the Appeals department. Our Medical Director will make a decision on your request, and we will let you know within 72 hours (3 days).
STATE FAIR HEARING FOR APPEALS
If you are dissatisfied with an Appeal decision, you may request a State Fair Hearing. In a State Fair Hearing, the Secretary of DHH will make a final decision on whether services will be provided. You must complete the Louisiana Healthcare Connections Appeals process before you can request a State Fair Hearing.
You may request a State Fair Hearing within 30 days of the date of the notice of resolution on your Appeal. If you request a State Fair Hearing and want your benefits to continue, you should file your request within 10 days from the date you receive our decision. If the State Fair Hearing finds our decision was right, you may be responsible for the cost of the continued benefits.
To request a State Fair Hearing:
- By mail: Division of Administrative Law, PO Box 4189, Baton Rouge, LA 70821-4189
- By Phone: (225) 342-5800
- By Fax: (225) 219-9823
- Online: http://www.adminlaw.state.la.us/HH.htm
You can download the DHH Request for State Fair Hearing Form here. For more information about to the State Fair Hearing process, contact the Health and Hospitals section of Division of Administrative Law at (225) 342-0443.
Free or low-cost legal services are available through the Legal Services Corporation. They have three offices in Louisiana. They may be contacted at the information below:
- Acadiana Legal Service Corporation
Program Phone: (337) 237-4320
Legal Assistance: 1-800-256-1175 (Toll Free)
- Legal Services of North Louisiana, Inc.
Program Phone: (318) 222-7186
Legal Assistance: 1-800- 826-9265 (Toll Free)
- Southeast Louisiana Legal Services Corporation
Program Phone: (504) 529-1000
Legal Assistance: 1-800-349-0886 (Toll Free)
The Advocacy Center
The Advocacy Center helps protect the rights of persons with mental or physical disabilities. They offer advice, information, training and legal help. Advocacy Center offices may be reached at the following locations:
- Advocacy Center–New Orleans
8325 Oak Street
New Orleans, LA 70118
Telephone: (504) 522-2337 or (800) 960-7705 Fax: (504) 522-5507
- Advocacy Center–Baton Rouge
8225 Florida Boulevard, Suite A
Baton Rouge, LA 70806
Telephone: (225) 925-8884 or (800) 960-7705 Fax: (225) 925-9625
- Advocacy Center–Lafayette
600 Jefferson Street Suite 812
Lafayette, LA 70501
Telephone: (337) 237-7380 or (800) 960-7705 Fax: (337) 237-0486
- Advocacy Center–Shreveport
2620 Centenary Boulevard
Building 2, Suite 248
Shreveport, LA 71104
Telephone: (318) 227-6186 or (800) 960-7705 Fax: (318) 227-1841
Grievances are spoken or written complaints submitted to Louisiana Healthcare Connections by you or your Authorized Representative. These complaints may concern any action of Louisiana Healthcare Connections, including, but not limited to:
- prior authorization requirements
- quality of care
- administrative processes or operations
Louisiana Healthcare Connections wants to resolve any concerns you may have. We will not hold it against you or treat you differently if you file a Grievance.
HOW TO FILE A GRIEVANCE
You can file a Grievance by mail at the address below or by fax to 1-877-401-8170. You can also call us at 1-866-595-8133 (TDD/TTY 1-877-285-4514) or file your Grievance in person at: Louisiana Healthcare Connections, 8585 Archives Avenue, Suite 310, Baton Rouge, LA 70809. If you’d like, you can use this Grievance and Appeal Form.
Be sure to include:
- Your first and last name
- Your Medicaid ID number
- Your address and telephone number
- What you are unhappy with
- What you would like to have happen
If you file a written Grievance, we will send you a letter within five (5) days letting you know we have received it.
If someone else is going to file a Grievance for you, we must have your written permission for that person to file your Grievance. You can call Member Services to receive a form or go to www.LouisianaHealthConnect.com. This Personal Appeal Representative Form can be used to give the right to file your Grievance or Appeal to someone else.
If you have any proof or information supporting your Grievance, you may send it to us and we will add it to your case. You may send this information to Louisiana Healthcare Connections by fax, in person or by letter. You may also request to receive copies of any documentation Louisiana Healthcare Connections used to make the decision about your care or Grievance.
You can expect a resolution and a written response within 90 days of your Grievance. Most Grievances are resolved within 30 days. If we need more than 90 days, we will contact you.
We will not hold it against you or treat you differently in any way if you file an Grievance. We want to know your concerns so we can improve our services.
Louisiana Healthcare Connections maintains records of each Grievance and Appeal, as well as all responses, for six years.