Department of Human Services fair hearings
In some cases, you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something AmeriHealth Caritas did or did not do. These hearings are called fair hearings. You can ask for a fair hearing at the same time you file a complaint or grievance or you can ask for a fair hearing after AmeriHealth Caritas decides your first or second level complaint or grievance.
What kind of things can I request a fair hearing about and by when do I have to ask for my fair hearing?
| If you are unhappy because… | You must ask for a fair hearing… |
|---|---|
| AmeriHealth Caritas decided to deny a service or item because it is not a covered service or item.within 30 days of getting a letter from AmeriHealth Caritas telling you of this decision. | |
| AmeriHealth Caritas decided to not pay a provider for a service or item you got and the provider can bill you for the service or item. | within 30 days of getting a letter from AmeriHealth Caritas telling you of this decision. |
| AmeriHealth Caritas did not decide within 30 days, a complaint or grievance you told AmeriHealth Caritas about before. | within 30 days of getting a letter from AmeriHealth Caritas telling you that we did not decide your complaint or grievance within the time we were supposed to. |
| AmeriHealth Caritas decided to deny, decrease or approve a service or item different than the service or item you requested because it was not medically necessary. | within 30 days of getting a letter from AmeriHealth Caritas telling you of this decision or within 30 days of getting a letter from AmeriHealth Caritas telling you our decision after you filed a complaint or grievance about this. |
| AmeriHealth Caritas did not provide a service or item by the time you should have received it. | within 30 days of the date you should have received the service or item. |
How do I ask for a fair hearing?
You must ask for a fair hearing in writing and send it to:
Department of Human Services
Office of Medical Assistance Programs
HealthChoices Program
Complaint, Grievance and Fair Hearings
P.O. Box 2675
Harrisburg, PA 17105-2675
Your request for a fair hearing should include the following information:
- Member name
- Member social security number and date of birth
- A telephone number where you can be reached during the day
- If you want to have the fair hearing in person or by telephone
- Any letter you may have received about the issue you are requesting your fair hearing for
What happens after I ask for a fair hearing?
You will get a letter from the Department of Human Services' Bureau of Hearings and Appeals telling you where the hearing will be held and the date and time for the hearing. You will receive this letter at least 10 days before the date of the hearing.
You may come to where the fair hearing will be held or be included by phone or video conference, if available. A family member, friend, lawyer or other person may help you during the fair hearing.
AmeriHealth Caritas will also go to your fair hearing to explain why we made the decision or explain what happened.
If you ask, AmeriHealth Caritas must give you (at no cost to you) any records, reports and other information we have that is relevant to what you requested your fair hearing about.
When will the fair hearing be decided?
If you ask for a fair hearing after a first level complaint or grievance decision, the fair hearing will be decided no more than 60 days after the Department of Human Services gets your request.
If your fair hearing is not decided within 90 days from the date that the Department of Human Services receives your request, you may be able to get your services until your fair hearing is decided. You can call the Department of Human Services at 1-800-798-2339 to ask for your services.
If you ask for a fair hearing and did not file a first level complaint or grievance, or if you ask for a fair hearing after a second level complaint or grievance decision, the fair hearing will be decided within 90 days from when the Department of Human Services gets your request.
What to do to continue getting services
If you have been receiving services or items that are being reduced, changed or stopped and your request for a fair hearing is hand-delivered or postmarked within 10 days of the date on the letter (notice) telling you that AmeriHealth Caritas has reduced, changed or denied your services or items or telling you Amerihealth Caritas' decision about your first or second level complaint or grievance, your services or items will continue until a decision is made.
What can I do if my health is at immediate risk?
Expedited fair hearing
If your doctor or dentist believes that using the usual timeframes to decide your fair hearing will harm your health, you or your doctor or dentist can call the Department of Human Services at 1-800-798-2339 and ask that your fair hearing be decided faster. This is called an expedited fair hearing. You will need to have a letter from your doctor or dentist faxed to 1-717-772-6328 explaining why using the usual timeframes to decide your fair hearing will harm your health.
If your doctor or dentist does not send a written statement, your doctor or dentist may testify at the fair hearing to explain why using the usual timeframes to decide your fair hearing will harm your health.
The Bureau of Hearings and Appeals will contact you to schedule the expedited fair hearing. The expedited fair hearing will be held by telephone within 3 business days after you ask for the fair hearing.
If your doctor or dentist does not send a written statement and does not testify at the fair hearing, the fair hearing decision will not be expedited. Another hearing will be scheduled, and the time frame for the fair hearing decision will be based on the date you asked for the fair hearing.
If your doctor or dentist sent a written statement or testifies at the hearing, the decision will be made within 3 business days after you asked for the fair hearing.
You may call the AmeriHealth Caritas toll-free telephone number at 1-888-991-7200; you can contact Legal Aid at 1-800-322-7572; or you can contact the Pennsylvania Health Law Project at 1-800-274-3258 if you need help or have questions about complaints and grievances.