Filing an Appeal
To file an Appeal by phone, call Member Services at 1-866-595-8133 (Hearing Loss: 711). 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 make your Appeal by phone or in person, you must also send Louisiana Healthcare Connections a letter confirming your Appeal within 15 days, unless you request an expedited appeal (see “Fast Appeal Decisions” below).
Louisiana Healthcare Connections will acknowledge your Appeal within five (5) 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 (Hearing Loss: 711) 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. You can also get this form from the Member Handbooks and Forms section of our website or in the forms section of the member handbook. If you want to allow someone to Appeal on your behalf, a “Personal Appeal Representative Form” must be sent in with your Appeal within 60 calendar days of the date on the Adverse Action letter.
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 (Hearing Loss: 711) 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 the Louisiana Department of Health 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 120 days of the date of the notice of resolution on your Appeal. If you request a State Fair Hearing and want the services being denied to continue, you should file a 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 services.
To request a State Fair Hearing:
- By mail: Division of Administrative Law,
PO Box 4189, Baton Rouge, LA 70821-4189
- By Phone: 1-225-342-5800
- By Fax: 1-225-219-9823
- Online: www.adminlaw.state.la.us/HH.htm
The “Request for State Fair Hearing Form” is located in the Forms section of your Member Handbook and on our website in the Member Handbooks and Forms section.
For more information about the State Fair Hearing process, contact the Health and Hospitals section of Division of Administrative Law at 1-225-342-0443.