An AHCCCS Fair Hearing Attorney may be necessary if an applicant faces denial of benefits or services of Available AHCCCS Health Plans. The Arizona Health Care Cost Containment System (AHCCCS) is the medicaid agency that offers health care programs which serves certain Arizona residents. An individual who is denied benefits or services by AHCCCS or the Arizona Department of Economic Security (“DES”) has the right to an appeal.  Applicants to AHCCCS must meet income requirements and and other obligations  to obtain health care services. However, if benefits or services are denied, and you will likely want to know more about Appealing AHCCCS Denial.  An appeal is a request for AHCCCS to reconsider or modify a decision. A common referral of a decision by AHCCCS is “an action.”  An action can include a denial, discontinuation, reduction or suspension of benefits or services.

Any individual who has received a Notice of Adverse Action by AHCCCS may request an appeal and if the appeal is denied an AHCCCS Fair Hearing.  However, the requirements for an appeal of an eligibility determination is slightly different than the appeal procedure for a person enrolled with an AHCCCS contractor, therefore, it is important to recognize the differences.  An adverse action may require knowledge of the AHCCCS Fair Hearing Process  An adverse action is defined as:

  • Denial of eligibility
  • Discontinuance of eligibility
  • Increase in the share of Arizona Long Term Care costs
  • Increase in premiums or co-payments
  • Failure by AHCCCS to make a determination within the established time-frame

Once the Notice of Adverse Action has been received the applicant must request a State Fair Hearing (“Hearing”) in writing with AHCCCS within 30 days.  The request for a Hearing must contain the case name, the adverse action taken by AHCCCS and the basis for the Hearing. Therefore, if AHCCCS receives a request for Hearing that is timely and contains the necessary information a Notice of Hearing is mailed to the applicant.  The Hearing usually is held between 30-60 days from the date the applicant requests a Hearing.

AHCCCS Denial of Services or Benefits include:

  • Suspension or denial of AHCCCS benefits
  • If there has been a denial of a wheelchair request
  • Denial of health care assistance
  • If there has been a denial of request for surgery

AHCCCS Fair Hearing Timeline:

  1. Ask for a service
  2. Service is denied by health plan
  3. Applicant must appeal the denial
  4. Health plan reconsiders the original decision
  5. If denied again Applicant must appeal for a Fair Hearing
  6. A hearing date is set.
  7. Fair Hearing is held before the Office of Administrative Hearings
  8. The AHCCCS makes a final decision.

AHCCCS Resubmission or Reconsideration

An initial request for a service may be denied due to missing documentation, incorrect coding or a lack of necessary information.  This denied request can be sent back to AHCCCS through a resubmission or reconsideration with the corrected or additional information.  The Resubmission must include:

  • The corrected claim;
  • Any additional documentation required;
  • A cover letter with “RESUBMISSION” written or typed on it;
  • A copy of the document where the request was denied.

The Reconsideration must include:

  • A copy of the original claim
  • Any additional documentation needed
  • A cover letter with “RECONSIDERATION” written or typed on it;
  • A copy of the document where the request was denied
  • A description of any correction.

If you’re interested in setting up a consultation with Chelle Law or learning more about our AHCCCS Fair Hearing Attorney services for Arizona residents reach out to us today.

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