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Complaints, Grievances, Appeals and Fair Hearings

Grievances

  • If you are unhappy with something that happened to you, you can file a grievance. Examples of why you might file a grievance include:
    • You feel you were not treated with respect
    • You are not satisfied with the health care you got
    • It took too long to get an appointment
  • To file a grievance, you should call Member Services at 202-408-4720 or 1-800-408-7511
  • Your provider can also file a grievance for you

You should file a grievance as soon as possible after the event that caused you to be unhappy. AmeriHealth Caritas District of Columbia will usually give you a decision within 30 days but may ask for extra time (but not more than 44 days total) to give a decision.

Appeals and fair hearings

If you believe your benefits were unfairly denied, reduced, delayed, or stopped, you have a right to file an appeal with AmeriHealth Caritas District of Columbia. If the resolution to the appeal is to uphold the decision, you then have the right to request a fair hearing with D.C.'s Office of Administrative Hearings.

        • To file an appeal with AmeriHealth Caritas District of Columbia, call Member Services at 202-408-4720 or 1-800-408-7511
        • To file a request for a fair hearing, call or write the District government at:

          District of Columbia Office of Administrative Hearings
          Clerk of the Court
          441 4th Street N.W., N450
          Washington, DC 20001
          Phone number: 202-442-9094

      • Deadlines:
        • You must file an appeal within 60 days of getting AmeriHealth Caritas District of Columbia’s adverse benefit determination
        • If you want to continue receiving the benefit during your appeal, you must request continuation of the benefit and file an appeal within the later of the following:
          • Ten days from the postmark of the notice of adverse benefit determination
          • The intended effective date of AmeriHealth Caritas District of Columbia’s proposed action (in other words, when the benefit is to stop)
      • You must request a fair hearing no more than 120 calendar days from the date the notice upholding the adverse benefit determination is mailed
      • Your provider may file an appeal or request a fair hearing on your behalf

Appeals

      • If you call and give your appeal over the phone, AmeriHealth Caritas District of Columbia will summarize your appeal in a letter and send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to AmeriHealth Caritas District of Columbia to make an appeal.
      • Your appeal will be decided by AmeriHealth Caritas District of Columbia within 30 calendar days from the date your appeal was received
      • If AmeriHealth Caritas District of Columbia needs more time to get information, and the District decides this would be best for you, or if you or your advocate requests more time, AmeriHealth Caritas District of Columbia may increase this time for the decision by 14 calendar days. AmeriHealth Caritas District of Columbia must give you verbal and written notice of the extension.
      • You will receive a call and written notice in the mail of AmeriHealth Caritas District of Columbia’s decision about your appeal
      • If you are not happy with AmeriHealth Caritas District of Columbia’s decision about your appeal, you may request a fair hearing

Expedited (emergency) grievances and appeals process

If your appeal is determined to be an emergency, AmeriHealth Caritas District of Columbia will give you a decision within 72 hours. An appeal is considered an emergency if it would seriously jeopardize your life; physical or mental health; or ability to attain, maintain, or regain maximum function if you had to wait for the standard time frame of the appeal procedure.

All appeals filed by enrollees with HIV/AIDS, mental illness, or any other condition that requires attention right away will be resolved and communicated back to the enrollee within 24 hours of filing the appeal.

Your rights during the grievances, appeals, and fair hearings process

  • You have the right to a fair hearing. You may request a fair hearing from the Office of Administrative Hearings after you have appealed the AmeriHealth Caritas District of Columbia adverse benefit decision and that decision was upheld on appeal.
  • If AmeriHealth Caritas District of Columbia does not give you notice regarding your appeal or does not give notice in a timely manner, then the appeal process will be considered complete and you may go ahead and request a fair hearing
  • You have a right to keep receiving the benefit we denied while your appeal or fair hearing is being reviewed. To keep your benefit during a fair hearing, you must request the fair hearing within a certain number of days. This could be as short as 10 days.
  • You have the right to have someone from AmeriHealth Caritas District of Columbia help you through the grievances and appeals process
  • You have a right to represent yourself or be represented by your family caregiver, lawyer, or other representative
  • You have the right, at no cost to you, to:
    • Have accommodations made for any special health care need you have
    • Adequate TTY/TDD capabilities and services for the visually impaired
    • Adequate translation services and an interpreter
    • See all documents related to the grievance, appeal, or fair hearing
    • Be notified 30 days before a major change in the complaint, grievance, appeal, or fair hearing processes