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- Eligibility Appeals
An eligibility appeal is a denial of an application for Medicaid . For questions regarding Eligibility Appeals please read the Eligibility Appeals FAQs below.
- Provider Appeals
A provider appeal is a denial for services rendered by a provider after any applicable reconsideration process has occurred. It also is an appeal form a determination from the Office of Program Integrity regarding an overpayment, suspension or termination of a provider.
- Other Appeals
This is a denial of a request for services by an enrolled member before services were provided.
Prior to filing an appeal on behalf of an enrolled member, you must have legal authority to do so, or have a completed Form 1282 signed by the member granting permission to act on their behalf.
FAQs
Please view the frequently asked questions (FAQs) related to the appeals process for information that can help you choose the right appeal process. The contents of the FAQs are for informational purposes only, and answers may vary by situation or hearing officer. Please read any orders or other communications received from a hearing officer carefully and follow any instructions given.
- Appeals and Hearings FAQs
What is an appeal?
An appeal is a request for a hearing because you do not agree with a decision made by SCDHHS, a Managed Care Organization (MCO), or another party acting on behalf of SCDHHS. The hearings are referred to as a "fair hearing."
Prior to a provider filing an appeal, they must exhaust their options through any applicable claims reconsideration process. If a provider has any questions about a denied claim, they can also contact the SCDHHS Provider Service Center at 888-289-0709.
When filing an appeal, you should include your full contact information (name, address, phone number, email, Medicaid number, etc.), state the reason(s) you disagree with the decision, and provide a copy of the notice. You can also include copies of additional documentation you want reviewed (i.e. medical records, bank statements, etc.). However, you will have an opportunity later in the process and during the hearing to introduce those documents.
What is a fair hearing?
A fair hearing is an in-person proceeding conducted by a hearing officer of the Office of Appeals and Hearings. During the hearing, the hearing officer listens the reasons as to why you disagree with the decision made by SCDHHS, the MCO, or another party acting on SCDHHS' behalf. The hearing officer will also listen to the other party explain the action taken on your appeal. Both sides can ask questions of the other party's witnesses. The hearing officer can also ask the witnesses questions. After the hearing, the hearing officer will issue a written decision in the case.
Where is a fair hearing held?
Most hearings are held at Jefferson Square, 1801 Main Street, Columbia, SC 29201. Occasionally, hearings may be scheduled by video on Webex or Microsoft Teams with the approval of the hearing officer.
What is a hearing officer?
A hearing officer is a neutral third party that presides over the appeal. The hearing officer guides the proceeding, which includes presiding over the hearing and issuing a final order.
A hearing officer is not a representative or advocate for any party at the proceeding, and he or she cannot provide legal or other advice to either party.
When can I appeal?
The following are some of the situations in which you can ask for an appeal (not an exhaustive list):
- You are denied eligibility.
- Your benefits or services are reduced, terminated, or suspended.
- SCDHHS or another party acting on SCDHHS' behalf denies your request for benefits or services.
- Your request for prior authorization is denied.
- A decision on your application or request for benefits has not been made in a timely manner.
- You receive notice that the nursing home where you reside plans to discharge or transfer you against your wishes.
How do I appeal?
You should carefully read the notice or denial you receive. It will contain instructions on how to appeal.
Please submit the appeal one of the following ways:
- Online. You will receive an electronic confirmation via email after submitting an appeal.
- Fax to (803) 255-8206
- Mail to the Office of Appeals and Hearings P.O. Box 8206 Columbia, SC 29202
- Email to appeals@scdhhs.gov
If you are enrolled in a Managed Care Organization (MCO), you should contact your health plan and work through its internal appeal process before filing an appeal with the Office of Appeals and Hearings.
If you are enrolled in waiver services through the South Carolina Department of Disabilities and Special Needs (SCDDSN), you should complete its reconsideration process before filing an appeal with the Office of Appeals and Hearings.
Can I ask for my hearing to be considered quickly?
An applicant or member may request an expedited appeal. SCDHHS may grant expedited review if we determine the standard appeal timeframe could jeopardize the individual's life, health, or ability to attain, maintain, or regain maximum function. SCDHHS may consider, among other facts:
- The medical urgency of the beneficiary's situation.
- Whether a needed procedure has already been scheduled.
- Whether a beneficiary is unable to schedule a needed procedure due to lack of coverage.
- Whether other insurance will cover most of the costs of the requested treatment.
If we grant your request to expedite, your appeal will be resolved as expeditiously as possible instead of the standard 90-day timeframe. If we deny the request to expedite, the appeal will follow the standard 90-day timeframe.
You may request an expedited appeal at the same time you file your appeal request or after you file an appeal. Please state you are requesting an expedited appeal and explain why. Requests can be filed on the Appeals website (www.scdhhs.gov/appeals), by fax, email, or mail.
To avoid delays in the process, please submit any supporting documentation with the request for expedited review or immediately thereafter. While supporting documentation is not required, SCDHHS will make its determination based on the information made available at the time we consider the request.
Who is an Eligibility Respondent Coordinator?
Eligibility appeals are routed to the Eligibility Respondent Coordinator (ERC), who will review the appeal request and determination. The ERC may be able to resolve your appeal request without a hearing. If the ERC can resolve the case, you will be notified. If the case cannot be resolved, the ERC will send you and the hearing officer a copy of an Eligibility Appeal Summary. This summary includes information about your eligibility determination. It can include supporting policy, any documents submitted with the application, the application itself, and other documents. Once the hearing officer receives the Eligibility Appeal Summary, he or she will continue with the appeal.
How long do I have to appeal?
You should carefully read the notice or denial you receive. It will contain instructions on the amount of time you have to file an appeal.
Can I ask for my services or benefits to continue?
New services cannot be started. However, you may request continued benefits or services if you make a request when filing your appeal and it is within ten days (10) of the date on the notice. Your services or benefits will continue during the appeal process. Any disputed benefits or services you receive during the appeal process may have to be paid back if the hearing officer finds the decision was correct.
Can someone ask for an appeal for me?
Yes, you may have a representative appear on your behalf for the appeal. You can also represent yourself.
Do I have to hire an attorney?
No, an attorney is not required. However, you may hire an attorney if you choose to do so. The attorney should file a notice of appearance with the hearing officer as soon as possible.
Can I contact the hearing officer?
A hearing officer cannot discuss the substantive issues of the appeal without both parties being present. Speaking to the hearing officer about issues in the appeal without either party involved is called an ex parte communication and is not allowed. The parties may speak to each other at any time without the hearing officer's involvement.
Can I receive communication and documents from the Office of Appeals and Hearings or Eligibility Respondent Coordinator electronically?
Yes, you can elect to receive all documents via email. This option is available when you file an appeal through the Appeals portal on the SCDHHS website. You can also elect to receive documents electronically by fax, email, or mail.
The Office of Appeals and Hearings will send you a written confirmation if you elect to receive correspondence electronically to your email address and ask you to confirm you received it. If the Office of Appeals and Hearings sends a message electronically and it is not returned as undeliverable, it is presumed to have been received.
- If the email is returned as undeliverable, it will be resent to the designated email address one more time. If it is returned as undeliverable again, the correspondence or order will be mailed. Please provide a current and working email address.
Do you need special accommodations?
You may need certain accommodations to complete the appeals process. For example, you may need a translator, interpreter, a Braille form, handicap-accessible parking, or assistance with transportation. If you require special accommodations, please contact the Office of Appeals and Hearings at (803) 898-2600 or (800) 763-9087.
What is a Petitioner?
A Petitioner is the person filing the appeal or the person on whose behalf an appeal is filed.
What is a Respondent?
The Respondent is the party whose decision is appealed.
What is a Pre-Hearing Conference Order?
A Pre-Hearing Conference Order generally requires the appealing party, the Petitioner, to contact the Respondent for an informal discussion about the appeal. The conference between the parties can be held in person, but it is not required.
After the conference is held, both parties must then provide a summary to the hearing officer of the issues discussed and what issues remain. The Petitioner must also indicate if they want to move forward with a hearing. If the parties settled the matter, the Petitioner should indicate if they want to withdraw the appeal request.
As with all orders and communications received from the hearing officer, please carefully review and follow all instructions. Failure to do so could result in the dismissal of your appeal.
Who will be present at my hearing?
The hearing will include at least the following:
- The hearing officer.
- The Petitioner and/or their representative.
- A representative for the Respondent.
- Any witnesses either party brings to testify.
- If there is no objection by either party and their attendance is not disruptive to the hearing, there may be observers, such as family members or other hearing officers.
What happens at the hearing?
Hearings have a more relaxed environment than courtrooms on TV or in movies. Typically, the hearing officer, the parties, and any witnesses meet around a table in a conference room.
Both parties have an opportunity to present an opening statement. Then, the Petitioner can present its witnesses and arguments. The Respondent is then allowed to cross-examine the Petitioner's witnesses. Then the Respondent presents its witnesses and arguments, with the Petitioner then being allowed to cross-examine.
Typically, the Respondent goes first in presenting their side. However, the hearing officer will determine the order of presentation. At the conclusion of the hearing, each party is given an opportunity to make a closing statement.
A decision will not be made the day of the hearing.
When will I get the order or decision from the hearing officer?
The hearing officer will make every effort to provide a timely decision. However, the timeframe can depend on several factors such as the amount of evidence and the complexity of the appeal.
Ordinarily, eligibility and member service appeals should be concluded within 90 days of filing. The 90 days can be affected by requests for an extension by the parties, the need for additional information, and difficulties in scheduling a hearing. There is no equivalent deadline for provider appeals.
You will receive the final order via certified mail.
Can I appeal the hearing officer's decision?
You may appeal to the Administrative Law Court (ALC). Directions on how to file an appeal to the ALC will be on the cover letter sent with the hearing officer's order. Please be aware that appeals must be filed with the ALC within thirty (30) days of receiving the hearing officer's order. For more information about appealing to the ALC, visit the ALC website or call (803) 734-0550.