If we do not tell you our decision about your appeal on time, you have the right to appeal to the State through the State Fair Hearing process. An untimely response by us is considered a valid reason for you to appeal further through the State Fair Hearing process.
We will tell you and your provider in writing if your request is denied or approved in an amount less than requested. We will also tell you the date of our decision, reason for the decision. And we will explain your right to appeal through the State Fair Hearing Process if you do not agree with our decision.
Your Right to a State Fair Hearing
If you disagree with our decision on your appeal request, you can appeal directly to DMAS within 120 calendar days from the date of our decision. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request for services within the times described in your handbook. The State requires that you first exhaust (complete) UnitedHealthcare Community Plan appeals process before you can file an appeal request through the State Fair Hearing process. If we do not respond to your appeal request timely DMAS will count this as an exhausted appeal.
Standard or Expedited State Fair Hearings
You may file a State Fair Hearing with DMAS when you disagree with our appeal decision or believe we have not resolved your appeal timely. For, appeals that will be heard by DMAS you will have an answer generally within 90 days from the date you filed your appeal with UnitedHealthcare Community Plan. The 90 day timeframe does not includethe number of days between our decision on your appeal and the date you sent your State fair hearing request to DMAS. If you want your State Fair Hearing to be handled quickly, you must write “EXPEDITED REQUEST” on your appeal request. You must also ask your doctor to send a letter to DMAS that explains why you need an expedited appeal. DMAS will tell you if you qualify for an expedited appeal within 72 hours of receiving the letter from your doctor.
You can give someone like your PCP, provider, friend, or family member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative.
Where to Send the State Fair Hearing Request
You or your representative must send your standard or expedited appeal request to DMAS by internet, mail, fax, email, telephone, in person, or through other commonly available electronic means. Send State Fair Hearing requests to DMAS within no more than 120 calendar days from the date of our final appeal decision. You may be able to appeal after the 120 day deadline in special circumstances with permission from DMAS.
You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the internet at http://www.dmas.virginia.gov. You should also send DMAS a copy of the letter we sent to you in response to your appeal.
You must sign the State Fair Hearing request and send it to:
Department of Medical Assistance Services
600 E. Broad Street
Richmond, Virginia 23219
Fax: (804) 452-5454
Standard and expedited State Fair Hearing may also be made by calling (804) 371-8488
For TANF members, you may appeal our decision to the External Review Organization at:
2810 N. Parham Rd, Suite #305
Henrico, VA 23294
After You File Your State Fair Hearing Appeal
DMAS will notify you of the date, time, and location of the scheduled hearing. Most hearings can be done by telephone.
State Fair Hearing Timeframes
Expedited State Fair Hearing
If you qualify for an expedited appeal, DMAS will give you an answer to your appeal If DMAS decides right away that you win your appeal, they will send you their decision. If DMAS does not decide right away, you will have an opportunity to participate in a hearing to present your position. Hearings for expedited decisions are usually held within one or two days of DMAS receiving the letter from your doctor. DMAS still has to give you an answer within 72 hours of receiving your doctor’s letter.
Standard State Fair Hearing
If your request is not an expedited appeal, or if DMAS decides that you do not qualify for an expedited appeal, DMAS will give you an answer within 90 days from the date you filed your appeal with DMAS. UnitedHealthcare Community Plan. The 90 day timeframe does not include the number of days between our decision on your appeal and the date you sent your State fair hearing request to DMAS. You will have an opportunity to participate in a hearing to present your position before a decision is made.
Continuation of Benefits
In some cases you may be able to continue receiving services that were denied by us while you wait for your State Fair Hearing appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for an appeal:
- Within 10 calendar days of the plan sending the notice of adverse benefit from being told that your request is denied or care is changing;
- By the date the change in services is scheduled to occur. The intended effective date of the plan’s proposed adverse benefit determination.
Your services will continue until you withdraw the appeal, the original authorization period for your service ends, or the State Fair Hearing Officer issues a decision that is not in your favor. You may, however, have to repay UnitedHealthcare Community Plan for any services you receive during the continued coverage period if UnitedHealthcare Community Plan’s adverse benefit determination is upheld and the services were provided solely because of the requirements described in this section.
If the State Fair Hearing Reverses the Denial
If services were not continued while the State Fair Hearing was pending
If the State Fair Hearing decision is to reverse the denial, UnitedHealthcare Community Plan must authorize or provide the services under appeal as quickly as your condition requires and no later than 72 hours from the date UnitedHealthcare Community Plan receives notice from the State reversing the denial.
If services were provided while the State Fair Hearing was pending
If the State Fair hearing decision is to reverse the denial and services were provided while the appeal is pending, UnitedHealthcare Community Plan must pay for those services, in accordance with State policy and regulations.
If You Disagree with the State Fair Hearing Decision
The State Fair Hearing decision is the final administrative decision rendered by the Department of Medical Assistance Services. If you disagree with the Hearing Officer’s decision you may appeal it to your local circuit court.