Peach State Provider Office Manual - Peach State Health Plan ...

EXPEDITED ADMINISTRATIVE REVIEWIf a decision on an Administrative Review is required immediately due to the member’s healthneeds, an expedited Administrative Review may be requested. Peach State’s decision will beprovided within 72 hours of Peach State’s receipt of the request for the review, subject to anauthorized extension of up to 14 days.ASSISTANCE AND CONTACTING PEACH STATEPeach State’s Appeals and Grievance Coordinator is available to assist members who need helpin filing a grievance or request for Administrative Review or in completing any element in thegrievance or Administrative Review process. Members may seek assistance or initiate agrievance or request for Administrative Review by calling 1-800-704-1484 (or TDD/TTY 1-800-659-7487).MEMBERS RIGHT TO AN ADMINISTRATIVE LAW HEARINGThe State will maintain an independent Administrative Law Hearing process as defined in theGeorgia Administrative Procedure Act (0.C.G.A Title 50, Chapter 13) and as required by federallaw, 42 CFR 431.200 et seq. The Administrative Law Hearing process shall provide MedicaidMembers an opportunity for a hearing before an Administrative Law Judge.A member, member’s authorized representative, or legal representative of a deceased member’sestate, upon receipt of an adverse determination regarding an administrative review, has the rightto request an Administrative Law Hearing. The Peach State Grievance and Administrative Reviewprocesses must be exhausted prior to requesting an Administrative Law Hearing. The requestmust be in writing and received by the Plan within 30 calendar days of Peach State mailing theNotice of Adverse Action.The parties to the Administrative Law Hearing shall include Peach State, the member ormember’s authorized representative, or legal representative of a deceased member’s estate. Aprovider cannot request an Administrative Law Hearing on behalf of a member. The request forthe Administrative Law Hearing should be mailed to the following address:Department of Community HealthLegal Services SectionDivision of Medical AssistanceTwo Peachtree Street, NW, 40 th FloorAtlanta, GA 30303-3159Information regarding the date, time, and place of the hearing is sent by the Office of StateAdministrative Hearings. An Administrative Law Judge will preside over the hearing. Themember has the right to present evidence, obtain representation for him or herself during thehearing, and have access to the case files.During the Administrative Law Hearing process, the member may request a continuation ofbenefits. The request must be in writing and received by the Plan within 10 calendar days ofreceipt of the notice advising that Peach State will not cover or pay for a service. Peach Statemust continue coverage until:• Ten calendar days have elapsed from the date the Plan’s initial adverse decisionwas mailed to the member, unless within the 10 calendar day timeframe themember submits a request for an Administrative Law Hearing with Continuationof Benefits until a decision is rendered by the Administrative Law Judge.• Benefit limitations are met or the authorization expires.• The Administrative Law Hearing request is withdrawn by the member.Provider Services1-866-874-063302/22/2011115