Service Appeals for Members

SERVICE APPEALS - STATE FAIR HEARING INFORMATION FOR TAILORED PLAN AND NC MEDICAID MEMBERS

If your Medicaid services are denied (turned down), you have a right to 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, it will be reviewed a second time by Sandhills Center. 

You have the right to appeal:

• Service denials
• Service reductions
• Limited authorization periods
• Suspensions or terminations of an already authorized service  

DENIALS

Your services may be denied if they do not meet certain criteria. You will receive a certified letter in the mail explaining why they were denied. The letter will explain how to ask for an appeal. Sandhills Center 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 not need the service as often, in the same amount, or for the same length of time. You will get a letter in the email 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 continue your service(s) through the end of your original authorization.   

HOW DO I APPEAL A MEDICAID DECISION?

If you get a letter from Sandhills Center telling you that some or all of your Medicaid services have been reduced, suspended, terminated or denied, you can ask for an appeal. You must follow all the directions in your notices and letters.

Questions? Call the appeals coordinator: 1-800-241-1073. 

Step One: The Reconsideration Request 

A reconsideration is the first step in appealing your decision before moving on to the State Fair Hearing through the Office of Administrative Hearings (OAH). A healthcare professional who has expertise in treating your condition will decide on your reconsideration request.

It can take up to 30 days for a decision to be made. You or your provider may request an expedited (faster) reconsideration if the standard review length could put your health and safety at risk. An expedited reconsideration will be reviewed within 72 hours. If your provider or representative asks for a reconsideration, you will be asked to sign a Consent to Release Information form. This form lets you give permission for your representative to ask for a reconsideration review for you.   

How do I file a Reconsideration Request? 

Complete and return the Reconsideration Request form by fax, by mail, or bring it to Sandhills Center. You can ask for a reconsideration form by calling Sandhills Center. You have 60 days from the date of your Decision on Your Request for Services letter to ask for a reconsideration. Your letter will tell you the deadline date. During this time, you and/or anyone you choose, including an attorney, may represent you. If someone represents you, you will be asked to sign a consent to release information form. You have the right to review any information that was used as part of the decision to deny, reduce, suspend, or terminate your service(s). You also can submit additional information that you believe helps you in your request for services. 

Submit Your Reconsideration Request:

• By phone: 1-800-241-1073, or by calling Member & Recipient Services: 1-800-256-2452 (TTY: 1-866-518-6778).
• By fax: 336-389-6543
• By mail or in person:

Sandhills Center Appeals Coordinator

185 Grant St.

West End, NC 27376  

– or –

Sandhills Center Appeals Coordinator

3802 Robert Porcher Way

Greensboro, NC 27410  

Step Two: The State Fair Hearing

If you disagree with the decision, you can submit another appeal to the North Carolina Office of Administrative Hearings. The State Fair Hearing request form will be mailed to you with the reconsideration decision letter. You must complete the reconsideration process before asking for a State Fair Hearing.

You must file your appeal with the North Carolina Office of Administrative Hearings (OAH) within 120 days from the date of your Decision on Your Appeal letter. After filing your appeal with OAH, you will be given a chance to have your case mediated. Mediation is a meeting with you, Sandhills Center, and an impartial facilitator. A facilitator is a neutral person who acts as the mediator to help resolve the situation. You may ask anyone to attend the mediation that you would like, including your provider or an attorney.

During the mediation, the mediator will help you and Sandhills reach an agreement that works for both parties. Mediation must be completed within 25 days of your request. If you decline (turn down) mediation or mediation does not work, your appeal will move on to a hearing. After the hearing, a judge will prepare a written final decision. When you get the final decision, either you or Sandhills Center will have a right to ask a judge to review it.  

Do I Have to Pay for My Services While Waiting for an Appeal Decision?

If the final decision is not in your favor, Sandhills Center has a right to bill you for the cost of the services you received during the appeals process.  

IMPORTANT TIMELINES TO REMEMBER

If you have been approved for a service and then it is later reduced, suspended, or terminated, we will tell you 10 days before change(s) are made to your service(s). If you appeal within 10 days of the notification, you may keep getting services. If a new service is denied or partly denied, we will let you know when the decision is made. You have 60 days from the date on the decision letter to ask for a reconsideration review. Sandhills Center will notify you of the reconsideration decision within 30 days of receiving your appeal request.      

For an expedited review, Sandhills Center will notify you of the reconsideration decision within 72 hours of receiving your appeal request. You can file an appeal with the North Carolina Office of Administrative Hearings within 120 days of the date of your Decision on Your Appeal letter.

Questions about the appeals process? Call the North Carolina Office of Administrative Hearings: 984-236-1860.

To learn about the reason(s) Medicaid will not pay for your service(s), call Sandhills Center Utilization Management: 1-800-241-1073.  

DO YOU NEED HELP WITH YOUR APPEAL?

The Sandhills Center Tailored Plan Utilization Management department staff can help you file your appeal. They are happy to assist you.

Call: 1-800-241-1073.

FREE LEGAL HELP MAY BE AVAILABLE:

• To find a lawyer near you, call 1-800-662-7660.
• Call the CARELINE (English/Spanish): 1-800-662-7030 (TTY: 1-877-452-2514).