Appeals and Grievances

Appeals

MedStar Family Choice Healthy DC Plan recognizes the right of a member and/or authorized representative or providers (i.e. clinician or facility) to request an Appeal of an Adverse Action (denial) that results in member financial liability or denied service. MedStar Family Choice Healthy DC Plan reviews all appeal requests of Adverse Actions and resolves appeals in a timely, appropriate manner. MedStar Family Choice Healthy DC Plan provides notice of the appeals process in a culturally and linguistically appropriate manner. Methods of informing members and providers about this process include articles in the newsletters, and sections in the member handbook and provider manual.

MedStar Family Choice Healthy DC Plan will accept appeal requests orally or in writing within applicable time frames. Appeal requests must include a clearly expressed request for the appeal or re-evaluation. The request must include the reason and supporting documentation as to why the Adverse Action (denial) was believed to have been issued incorrectly.

Please note: Members must complete and sign to designate an authorized representative to act on their behalf for requests related to claims, appeals, and grievances.

Member Appeals

A member, representative (e.g. parent, guardian, friend, etc.), or provider (e.g. clinician or facility) acting on behalf of a member may request an appeal of an Adverse Action when the service has not yet been provided (pre-service), there is reduction of services, or the service has already been provided and there is member financial liability.

Members must provide written consent for a provider or representative to appeal on their behalf via the Provider Permission Form for Member Appeals or any other format. The Appeal Review process begins at the time MedStar Family Choice Healthy DC Plan receives the member’s consent.

All member appeals must be submitted in writing within 180 calendar days from the date on the Adverse Benefit Determination (denial) notice. The member may initiate an appeal orally. However, a written appeal request with all supporting documentation, such as clinical/medical documentation must be sent to MedStar Family Choice Healthy DC Plan for review. Please include an explanation for the appeal (why the member / provider believes the service was denied incorrectly). Complete all required fields on the Medicaid Appeal Form and submit with the appeal.

MedStar Family Choice Healthy DC Plan will send a letter to acknowledge receipt of the appeal within two (2) business days of receipt of the member appeal request. A decision letter will be sent within thirty (30) days from the date the appeal request was received for standard non-urgent requests. 

Required documentation:

• Medicaid Appeal Form
• Explanation for the appeal
• Provider Permission Form for Member Appeals
• Clinical information (medical records) for date of service

If you have questions, please call us at 800-905-1722, option 3.

Clinical/Medical Necessity appeal requests can be faxed to 410-350-7435.

Administration/Claim appeal requests can be faxed to 410-350-7455.

If the appeal is more than 50 pages, please use our mailing address below for all provider and member appeal requests:

MedStar Family Choice DC
Appeals Processing
P.O. Box 43790
Baltimore, MD 21236