Appeal a denial by your health plan

Most people on Washington Apple Health get their medical coverage through an Apple Health Managed Care plan: Coordinated Care, Molina Healthcare of Washington, Wellpoint Washington (formerly Amerigroup), UnitedHealthcare Community Plan, or Community Health Plan of Washington. If your Apple Health Managed Care plan denies coverage of treatment, medication, or medical care you need, you have the legal right to appeal. 

You should appeal right away -- as soon as you get the letter from the Apple Health Managed Care plan terminating or denying you medical care that you need. 

If you’re currently getting medical treatment that you want to continue while you appeal, you must file the appeal within 10 days of the date on the denial or termination notice. You must do this even if your provider has arranged a “Peer-to-Peer” conversation with the health plan.  If you don’t file your appeal within 10 days, the Apple Health Managed Care plan may stop covering the treatment or care (deny you continuing benefits) while the appeal is pending.

The health plan’s letter denying you the treatment or service you need should include information on how to file an appeal. The best way is to send a fax or email to the address in the denial letter. Health plans are supposed to process appeals over the phone, but it’s best to appeal in writing so you have proof that you appealed and the date of your appeal.

If your health care needs are urgent, you can request an “Expedited Appeal.” The health plan must make its decision within 72 hours.

In your appeal, you should explain why the decision is wrong and why you need the medical care. If you have any additional medical evidence that the plan didn’t have for the original request, submit it now. 

Your medical provider might already have filed an appeal for you. Check to make sure. You’re still responsible for making sure the appeal is filed on time. 

It depends on the reason for the denial letter. The Apple Health plan may deny care because they think it isn’t “medically necessary.” Or they may deny care you need because they say it’s “cosmetic.” You must gather medical evidence that shows why their decision, no matter the reason, is wrong. 

Contact your medical provider to review the denial and to see if they will write a supporting letter or provide additional information for your appeal.

You can appeal that decision to the Office of Administrative Hearings. Then an independent judge who doesn’t work for the health plan will review your appeal. There are different ways you can do this.

• In writing: Write the Office of Administrative Hearings (OAH), P.O. Box 42488,
  Olympia, WA 98504.
• Verbally: You can call OAH at (360) 407-2700 or 1-800-583-8271 or tell the health plan that you want a hearing. The health plan may have you follow up with a written request.
• If it’s an emergency, you should call OAH at (360) 407-2700 or 1-800-583-8271 to ask them to hold the hearing as soon as possible. This is called an expedited hearing. 

If you call to make this second appeal request, have a copy of the health plan’s second denial notice (the denial of your first appeal) with you. 

Again, if you’re currently getting medical care that would end, you must make your second appeal within 10 days of the date on the health plan’s letter upholding the denial to keep your care during the appeal. Once you’ve made your second appeal request, try to get legal help. Your appeal of a denial of health care by your health plan is a legal issue.

While you’re waiting for your appeal hearing date, ask the health plan to send you all the information (“evidence”) they relied on in making their denial decision. You should do this in writing if possible. That way you have a copy of your request and when you made it.

Save everything! You may have to show that you did appeal within 10 days (both with the health plan and OAH). Also, if the health plan doesn’t send you the information they relied on, you have proof of asking for it and when.

Keep a written record of what you asked for, when, and how, a copy of anything you sent in writing, and any response or records you get.

Read any written notice the plan sends you about a decision it made that’s unfavorable to you. Make sure you understand its reason. Note any deadlines. 

If it’s an emergency, you should call OAH at (360) 407-2700 or 1-800-583-8271 to ask them to hold the hearing as soon as possible. This is called an expedited hearing.

Otherwise, your hearing will probably be 20 days or more after you ask for it. 

Yes. OAH must make sure its services and hearings are fully available to all persons with disabilities. OAH may need to change the way it handles a hearing or communicates with you to make sure you have the same chance to take part in a hearing as someone without disabilities. 

You can use their online form to ask for an accommodation of your disability. Or you can make your request by calling (360) 407-2700 or (800) 583-8271. TTY (hearing impaired) users dial 7-1-1 or 1-800-833-6388 for the Washington relay operator. 

It might help to have ready some suggestions for how OAH can accommodate your disability. If OAH refuses to accommodate you, you can file a complaint.

You can ask the Board of Appeals to review the fair hearing decision. Do this as soon as you can after receiving the unfavorable decision. There are a few different ways to make this request: 

• By mail to Board of Appeals – Health Care Authority, P.O. Box 42700,
  Olympia, WA 98504-2700.
• By hand delivery to the Board of Appeals at 626 8^th Ave. S.E., Olympia WA.
• By fax to the Board of Appeals at 1-360-507-9018. You must also mail a copy. 

Your BOA review request should say why the fair hearing decision was wrong and list testimony and written materials from your fair hearing supporting your view. You can’t provide any new information or records at this stage of the process.

If you disagree with the BOA’s decision, you may appeal it to Superior Court. The deadline for filing is 30 days after the date the BOA mails the decision to you. The process is complicated. Get help or advice from a lawyer. 

Ask for an Exception to Rule (ETR) for services the plan says it doesn’t cover (“non-covered” services). If the plan grants your ETR request, you may not need to file a grievance or appeal. At the same time, you can still appeal the plan’s decision that the service isn’t covered if you disagree with that. 

For a child or youth under age 21, you must make an appeal, not an ETR.