Service Appeals for Non-Medicaid Services
If you are a recipient of State-Funded services and your services are denied (turned down), you can appeal that decision. To appeal means that you disagree with the decision and you ask, in writing, to have the decision reviewed. After submitting your appeal request, it will be reviewed a second time by the Sandhills Center Tailored Plan.
You have the right to appeal:
- Service denials
- Service reductions
- Limited authorization periods
- Suspensions or terminations of an already authorized (approved) service
Your services may be denied if they do not meet certain criteria. You will get a letter in the mail that tells you the reason for this decision. The letter also will tell you how to request an appeal. The Sandhills Center Tailored Plan will not pay for the denied service during the appeal process.
REDUCTIONS, SUSPENSIONS, OR TERMINATIONS
Services that already are approved, or authorized, may be reduced, suspended (put on hold), or terminated (ended) for many reasons. For example, the provider may not be following clinical guidelines, or you may no longer need the service as often, in the same amount, or for the same amount of time. You will get a certified letter in the mail at least 10 days before any changes are made to your service(s). The letter will tell you how to ask for an appeal. If you ask for an appeal by the deadline stated in the letter, you may be able to keep getting your service(s) through the end of your original authorization.
HOW DO I FILE A NON-MEDICAID APPEAL?
To request an appeal, complete and return the appeal request by fax, mail or bring the form to Sandhills Center. You have 15 days from the date of your Decision on Your Request for Services letter to ask for an appeal. Your letter will tell you the deadline date. During the appeal, you and/or anyone you choose, including an attorney, may represent you. If someone represents you, you will be asked to sign a form that allows them to get information about you. You have a right to review all information that is used in making the decision to deny, reduce, suspend or terminate your service(s). You also can submit any information that you believe will help you in your request for services.
Submit your Non-Medicaid Appeal Request:
- By fax: 1-336-389-6543
- By mail or in person:
Sandhills Center Appeals Coordinator
185 Grant St. (P.O. Box 9)
West End, NC 27376
Sandhills Center Appeals Coordinator
3802 Robert Porcher Way
Greensboro, NC 27410
Step One: The Non-Medicaid Appeal
A non-Medicaid appeal is the first step in appealing your decision before moving on to the Non-Medicaid Appeals Panel. A health care professional who is experienced in treating your condition or disorder makes the appeal decision. It can take up to 7 days for an appeal decision to be made. You or your provider may request an expedited appeal if the standard review length could put your health and safety at risk. An expedited appeal means you will get a decision quicker. Your appeal will be reviewed within 72 hours.
If your provider (or someone representing you) requests an appeal, you will be asked to sign a Consent to Release Information form. The form allows them to get information about you.
Step Two: The Non-Medicaid Appeal Panel
If you do not agree with the appeal decision, you may submit another appeal to the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services (NC DMH/DD/SA). They will gather a panel of professionals to review your case. You must file your request for a Non-Medicaid Appeal Panel within 11 days from the date of the Decision on Your Appeal letter. You must file your request for a Non-Medicaid Appeal Panel in writing. The Decision on Your Appeal letter has instructions for asking for a Non-Medicaid Appeal Panel.
You will be invited to go to the Non-Medicaid Appeal Panel to show them your case. Your representative also can go with you or may go in your place. The panel will review your case and make a decision based on its findings. The panel will issue a decision to Sandhills Center. It can take up to 60 days for the panel to issue its decision. Sandhills Center will consider the panel’s decision. However, Sandhills Center will make the final decision about your case. In most cases, Sandhills Center will follow the decision of the Non-Medicaid Appeal Panel. Sandhills Center will send you the final decision in writing within 10 days of getting it from the Non-Medicaid Appeal Panel.
IMPORTANT TIMELINES TO REMEMBER
If a new service request is denied or partly denied, you will be notified when the decision is made. You have 15 days from the date on the decision letter to ask for a non-Medicaid appeal. Sandhills Center will let you know about the appeals decision within 7 days of getting your appeal request. For an expedited appeal, Sandhills Center will let you know about the appeal decision within 72 hours of getting your appeal request. You can ask for a review by the Non-Medicaid Appeal Panel within 11 days of the date of your Decision on Your Appeal letter.
DO YOU NEED HELP WITH YOUR APPEAL?
The Sandhills Center Tailored Plan can help you file your Medicaid or Non-Medicaid Appeal. Our staff is trained in the appeal process.
Need help? Call the Sandhills Center Utilization Management (UM) department at 1-800-241-1073.
Free legal aid may be available:
- To find a lawyer near you, call 1-800-662-7660.
- Call the toll-free CARELINE (English/Spanish): 1-800-662-7030 (TTY: 1-877-452-2514).