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Apple Health providers When does a provider have a right to a hearing? When does an applicant or recipient have a right to a hearing? Resources for Apple Health applicants and recipients To request an administrative hearing, or if you want an interpreter or other help to request a hearing: Complete any form that came with your letter and fax to Call or Apply online or: If under age 60, call If age 60 or over, call How do I get dental care?

Can I get vision care? Are my dependents eligible? Are my survivors eligible? Manage benefits What is special open enrollment? Change my coverage Change my address Cancel my coverage What happens if I stop working? Learn how to enroll How do I enroll?

If we do this, a letter will be mailed to you and your provider for services that are not approved. This letter is called a notice of Adverse Benefit Determination letter formally known as Notice of Proposed Action letter or a denial.

The adverse benefit determination letter will explain how you, someone on your behalf or your doctor with your consent can ask for an administrative review appeal of the decision. An appeal may be filed orally by phone, or in writing mail or fax. This needs to be within 60 calendar days of when you get the notice of adverse benefit determination denial notice.

You must give written permission if a provider files an appeal for you. Contact us if you need help filing the appeal. Also, you can look at your medical records and information on this ruling before and during the appeal process. Eastern time. Peach State Health Plan will look at your request and judge if your request deserves a fast decision. If we decide your case requires a fast decision, we will make a decision and provide a determination within 72 hours. If you have a special need, we will give you extra help to file your appeal.

A State Fair Hearing is a hearing before an Administrative Law Judge when you want Peach State Health Plan to reconsider and change a decision or action we have made about what services are covered for you or what we will pay for a service.

A request for a State Fair Hearing must be made in writing within calendar days from the date of the Appeal Decision Notice. You can request this review in writing. When you request this in writing, you will include your request for a hearing, along with a copy of the appeal determination letter.

If you want your benefits to continue, while awaiting the completion of your State Fair Hearing, you must request a continuation of care, in writing, within ten 10 calendar days from the date we mailed the Appeal Decision Notice, which can be up to calendar days.

But you may have to pay for this care, if the decision is not in your favor. Please see the section Continuation of Benefits below. You must complete the Appeal process before proceeding to the State Fair Hearing. Your provider cannot request a State Fair Hearing on your behalf.

The Office of Administrative Hearings will tell you the date, time, and place of the hearing. You can speak for yourself or your representative may speak for you. You can get help from a lawyer. You may be able to get free legal help. The decision reached by the State Fair Hearing is final.

If you need help requesting a State Fair Hearing or need an interpreter, call Member Services at If you want your benefits to continue while awaiting the completion of your Appeal Review or State Fair Hearing process, you must request a continuation of care on or before the later of the following:.

You may have to pay for the cost of continuation of your benefits if the final decision is not in your favor. If the decision is made in your favor, Peach State Health Plan will approve and pay for requested services that are needed but were not received during the review of your case as quickly as possible.

If the decision is made in your favor and you did receive continuation of benefits during the review of your case, Peach State Health Plan will pay for those services. An appeal may be filed orally by phone, fax it, or in writing mail or fax.

A request for a Formal Grievance Committee review must be made in writing within thirty 30 calendar days from the date of the Appeal Decision Notice. You request this review in writing. When you request this in writing, you will include your request for a Formal Grievance Committee Review, along with a copy of the appeal determination letter.

If you want your benefits to continue, while awaiting the completion of your state review, you must request continuation of care, in writing, within ten 10 calendar days from the date of the Appeal Decision Notice. Your provider cannot request a Formal Grievance Committee Review on your behalf.

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