Claims, Appeals, and Grievances

Providers acting on their own behalf are defined as those who dispute Adverse Actions when the service has already been provided to the enrollee and there is no enrollee financial liability. First level appeals must be submitted in writing within 90 business days from the date of the explanation of benefits (EOB) or denial notice, using the Medicaid Appeal Form. The appeal must outline reasons for the appeal with all necessary documentation including a copy of the claim and the EOB, when applicable. Appeal requests for medical necessity decisions must include supporting clinical/medical documentation.

A provider appeal must include a clearly expressed reason for re-evaluation, with an explanation as to why the denial was believed to have been issued incorrectly. MedStar Family Choice Healthy DC Plan will send a letter to acknowledge receipt of the appeal within five (5) business days of receipt of the 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. 

For questions, please call our Provider Customer Service Line at 800-261-3371, which is available Monday through Friday, 8:00 a.m. to 5:30 p.m.

Instructions for Completing the Medicaid Appeal Form:

• Fields designated by an asterisk (*) are required.

• The form must be completed in its entirety to prevent delay in processing the appeal.

• Use one appeal request per form.

• Medical records must be submitted for medical necessity requests.

• Submit a copy of the claim (Only for Administrative appeals).

• Must select Plan Type (DC), Appeal Type (Clinical or Claims) and the Appeal Level (I).

Member appeals only have one level. 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 60 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