Appeals Can Be Confusing, We're Here to Help

During the COVID-19 public health emergency and the years that followed, DMAS temporarily paused denials of requested personal care hours. As a result, some individuals were approved for more hours than would typically be authorized under standard guidelines. In recent years, Managed Care Organizations have updated their review processes to better align with DMAS requirements, leading to reductions in authorized hours across plans.

Reductions in authorized hours can occur for a variety of reasons, including prior over-authorization. Below are two very common scenarios:

• Medical Directors base their decisions on the information provided by your Care Manager and/or Service Facilitator/Agency. If the documentation is incomplete or does not accurately reflect your needs, it may result in a reduction of authorized hours. This is why choosing an experienced and thorough Service Facilitator is so important.

• Similarly, if the information you provide to your Care Manager or provider is incomplete, they may not be able to fully advocate on your behalf. It is important to be prepared for all assessments and to clearly communicate your medical history, personal care needs, and any relevant events that support your need for personal care hours.

A physician letter can help establish your diagnostic history and explain how your conditions impact your need for personal care. However, a physician’s order for a specific number of personal care hours is not binding. Authorization decisions are made by MCO Medical Directors in accordance with Medicaid guidelines.

It’s important to understand that diagnoses alone do not determine personal care hours—functional care needs do. While submitting medical history is helpful, appeals that focus only on diagnoses are less likely to result in a change. Documentation should clearly explain how conditions impact your ability to perform daily activities and identify the specific steps where assistance is needed.

Your decision letter will outline the timeframe to file an appeal. It is important to keep documentation of all steps taken during the appeal process. Be sure to record who you spoke with and retain any confirmations—such as fax receipts or mailing receipts with tracking or certification. You may be asked to demonstrate that you followed the instructions outlined in your letter.

It can be difficult to appeal a decision if you do not understand how it was made. You have the right to request the documents used in determining your hours. Specifically, ask for copies of your Health Risk Assessments, NCQA Summary Statements, Level of Care Review Instrument (for CCC Plus), and any documentation or calculation tools used to determine your authorized hours. Once you receive these documents, review them carefully to identify any inaccuracies or missing information that may support your appeal. You can also work to obtain additional supporting documentation—such as letters from your physicians—to address and clarify any areas that may need correction.

Keep track of your requests—when you made them, who you spoke with, and any confirmations you received. This can help if you need to follow up or show that the information was not provided.

During the appeal process, a different physician within your MCO will review the original request, the Medical Director’s decision, and any additional information you provide. If they determine that important information was overlooked, they may overturn the original decision. This is why it is important to understand how the original decision was made.

If the original decision is upheld, you will have the option to appeal at a higher level through a State Fair Hearing. At this stage, reviewers outside of your MCO will evaluate all available information, as well as how the decision was made, to ensure it aligns with medicaid guidelines. It is important to understand that these are two separate processes—filing an appeal with your MCO does not automatically initiate a State Fair Hearing. You must follow the instructions in your appeal outcome letter to request this next level of review.