RespiteMatch.com Health Blog

Learn How To:
Y Ask AHCCCS to Review Your Health Plan’s Decision
Y Get the Records and Letters That You Need to Prove Your Case to AHCCCS
Y Make Your Case at an AHCCCS Hearing

Arizona Center for Disability Law
Self-Advocacy Guide
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B
If you get health care through an AHCCCS plan such as Mercy Care or APIPA and your plan has told you that they will not give you the services or equipment you need, there are steps you can take to try to get those services. This guide will tell you:
1. How to ask AHCCCS to review your health plan=s decision.
2. How to ask for a fair hearing.
3. How to get records and letters that will help you prove to AHCCCS that you need the service that your health plan will not provide.
4. How to make your case at an AHCCCS hearing.
1. Asking AHCCCS to Review Your Health Plan=s Decision
If your health plan told you they will not provide a service or piece of equipment that you need, like attendant care or a wheelchair, you can:
# Write a letter or call your health plan and ask them to review their decision. This is called filing an appeal.
# In many cases, you may be able to keep getting the services that you were getting before you got the denial letter from your health plan. If you want services continued, you should call or write your health plan immediately and let them know you want services continued.
# Note: It is best to make your request in writing and send it certified mail with a return receipt or by facsimile with a confirmation sheet. This way you can prove when you made your request.
2. Asking AHCCCS for a Hearing
If after reviewing your case, the health plan still won’t provide a service or piece of equipment that you need, you can ask for a hearing. At the hearing, you will get a chance to tell an administrative law judge why you need the service or equipment that your health plan will not provide.
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If you want to ask AHCCCS for a hearing, you need to:
# Read the letter that the health plan sent you telling you that they will not provide you with the service or equipment that you need.
# Write your health plan and ask for a hearing. The letter from your health plan will say how soon you have to do this. (You have 10 days if you want services continued.) If you do not ask for a hearing during the time the letter says you can, you will not be able to get a hearing.
Ask for a hearing.
After you ask for a hearing, you will get a letter from AHCCCS. There is a sample letter on page 7 of this guide. The letter you get will tell you:
# The date, time and place where the hearing will be.
The hearing will be at a place called the Office of Administrative Hearings (OAH).
# The name of the judge who will be at the hearing.
To get the services you want, you must go to the hearing!
3. Getting the Records and Letters That You Need to Prove Your Case to AHCCCS
Before your hearing, you will need to get records and letters from your health plan and your doctor. These will help you prove to AHCCCS that you need the service or equipment that your health plan will not provide. Take the following steps to get the records and letters you need:
# Write a letter to your health plan. Ask them to mail you a copy of your file. Your file may have important information about why your health plan will not provide the service or piece of equipment you need. Also, ask your health plan to send a copy of the letters, records
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and other information that they will bring to the hearing. See the sample letter on page 8 of this guide.
# Ask your doctor to write you a letter. The letter should list:
# Your medical condition, with your exact diagnosis.
# How long your condition will last.
# Why you need the service or equipment that has been denied.
# What health problems will occur if you don’t get the service or equipment.
This type of letter is sometimes called a letter of medical necessity. Page 9 of this guide has a sample letter written by a doctor.
Note: If your health plan or your doctor won=t give you your records, you can ask the judge that is listed in your hearing notice to order them to do it (subpoena). For more information on how to get a subpoena, call the Office of Administrative Hearings at 602-542-9826 or visit their web site at www.azoah.com.
• Requests for witness to testify by telephone.
You can have your doctor, a therapist or even a friend come with you to the hearing or speak to the judge over the phone. If you want someone to speak to the judge over the phone, you must fill out a form. You will get the form from AHCCCS when they send you the letter about the date of your hearing. You should make this request 15 days before the hearing date.
List the reasons you need the service or equipment.
4. Making Your Case at an AHCCCS Hearing
Before the hearing:
# Write a list of points you want to make at the hearing.
# List the reasons you need the service or equipment that your health plan will not provide.
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# Read the letters and records you got from your health plan and your doctor. See how they can help you prove your case to the judge.
At the hearing, this is what usually happens:
#1 You will present your case.
You will tell the judge why you need the service or piece of equipment that your health plan will not provide.
If there are other people who can help you explain to the judge why you need the service or equipment, they should speak too.
Use the letters or records you have from your health plan and your doctor to help prove your case.
#2 A person from your health plan will ask you questions.
#3 The person from your health plan will present the company’s case. They will explain why they will not provide the service or piece of equipment.
Tell the judge why you need the service or piece of equipment.
#4 You will then ask the person from your health plan questions.
#5 You and the person from the health plan will have a last chance to say why you should or should not get the service or piece of equipment.
#6 The hearing officer will send you a decision letter a few weeks after the hearing.
Bring the following things to the hearing:
􀂃 Your medical records and the letter from your doctor that says you need the service or piece of equipment.
􀂃 Any letters sent between you and your health plan or other information that will help you make your case.
􀂃 A list of the points that you want to make.
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􀂃 A list of the questions that you want to ask your health plan.
􀂃 Paper and a pencil C to take notes.
If you do not win at the hearing, the judge=s decision letter will tell you the next steps you can take to try to get the services you need to stay healthy.
If you have questions about this guide or other questions about your legal rights as a person with a disability, please write the Arizona Center for Disability Law at:
3839 North Third Street 100 North Stone
Suite 209 Suite 305
Phoenix, AZ 85012 Tucson, AZ 85701
Call: 602-274-6287 (voice or TTY) Call: 520-327-9547 (voice or TTY)
800-927-2260 (toll free) 800-922-1447 (toll free)
602-274-6779 (fax) 520-884-0992 (fax)
e-mail: center@acdl.com
If you would like to know more about classes you can take at the Arizona Center for Disability Law or if you want to read more about how to help yourself and your family, visit our web site at:
www.acdl.com
Funding for this document is provided by the United States Department of Health and Human Services - Administration on Developmental Disabilities and Center for Mental Health Services, United States Department of Education - Rehabilitation Services Administration.
Federal and state law can change at any time. If there is any question about the continued validity of any information in the handbook, contact the Arizona Center for Disability Law or an attorney in your community.
The purpose of this guide is to provide general information to individuals regarding their rights and protections under the law. It is not intended as a substitute for legal advice. You may wish to contact the Arizona Center for Disability Law or consult with a lawyer in your community if you require further information.
‘ This guide is available in alternative formats upon request
Revised 05/17/05
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AMENDED NOTICE OF HEARING FOR AHCCCS-RELATED MATTERS
October 30, 2000
RE: v. Department of Economic Security/DDD & AHCCCS Administration
NAME: ID#
Scottsdale, Arizona 85255 OAH Docket #:
AHCCCS Grievance/Appeal #
Dear parties:
The Arizona Office Of Administrative Hearing (OAH), the Agency designated by State Law to conduct hearings on behalf of the AHCCCS Administration, has scheduled a hearing to be conducted on the following date and location:
Date: November 14, 2000
Time: 11:00 a.m.
Location: 1400 West. Washington, Suite 101, Phoenix, Arizona 85007
The issue to be addressed at the hearing is medical necessity of environmental modification as provided for in A.R.S. § 36-2909; A.A.C. R9-22-101(B),
R9-28-201, R9-28-205.
OAH has appointed Neal H. Jordan, Administrative Law Judge, to conduct the hearing in accordance with A.R.S. § 36-2903.01 (B)(4) and A.A.C. R9-22-801 et seq.
Members and applicants may present evidence at the hearing with or without the assistance of counsel. Members and applicants may also be represented by agents who are not charging a fee. A legal entity may be represented by a full-time employee who is not charging an additional fee for representing the entity and whose primary responsibility is not to represent the legal entity.
Please note that the original of all correspondence and pleadings related to this matter must be filed with OAH at 1400 West Washington, Suite 101, Phoenix, Arizona, 85007. Copies of the correspondence must also be filed with all other parties and to the AHCCCS Administration, Office of Legal Assistance at P.O. Box 25520, Phoenix, Arizona, 85002. In preparation for this hearing, the AHCCCS Administration has forwarded a copy of the case file to OAH.
In accordance with A.R.S. §41-1092.08, the Administrative Law Judge shall provide the Director of the AHCCCS Administration a written decision within 20 days of the conclusion of the hearing. The Director of AHCCCS must then accept, reject or modify the Decision of the Administrative Law Judge within 30 days or the Administrative Law Judge Decision will become the final decision. Parties also have the opportunity to file a Motion for Rehearing or Review of the Director’s Decision.
Persons with disabilities or special needs, including interpreters, may request reasonable accommodations. Requests should be made as soon as possible, but no later than 72 hours prior to the hearing. Please direct all requests for accommodations to OAH, at (602) 542-9826 or 1-877-203-0226. Friends, family or representatives of either party may not serve as interpreters.
Requests for telephonic hearings and continuances must be made in writing to OAH at least 15 days before the hearing in accordance with P2-19-106. Complete the attached forms and submit to OAH.
Sincerely,
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S
SAAMMPPLLEE
February 19, 2002
Mercy Care Plan
2626 East Indian School Road
Phoenix, Arizona 85013
Re: Bob Jones
Date of Birth: 09/25/62
Member ID: 0 1 68231
Dear Sir or Madam:
Please send any and all documents, records and correspondence related to your denial of a power wheelchair for me within 10 days. The documents, records and correspondence should be sent to:
Bob Jones
235 Pine Road
Phoenix, Arizona 85007
Also, please send any information that you plan to present at the AHCCCS hearing scheduled for March 22, 2002, as I am entitled to that information at least 5 days in advance of the hearing.
Thank you for your time and attention to this request.
Sincerely,
Bob Jones
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TO:
FROM:
DATE: December 21, 2001
RE:
To Whom It May Concern:
is a patient in my care for arthrogryposis. She is a bright young lady who has significant limitations due to lower extremity deformities. She has had multiple surgeries, but still requires a wheelchair for ambulation.
I am requesting that you provide her with a manual wheelchair in addition to the electric wheelchair she generally uses. The purpose of this request is two-fold: Safety and therapy.
She has already had a significant injury related to the electric wheelchair. The controls on her chair were accidentally triggered at the top of her stairs, propelling her down the stairs. She was thrown out, down the stairs, dislocating her elbow. A manual wheelchair would be much safer for her routine use around the house. The home has limited space which makes it difficult to maneuver the electric wheelchair.
She also has significant difficulty with obtaining physical therapy. We are in a rural community with no physical therapist readily available. It would be very beneficial for her to use a manual wheelchair to assist in building and maintaining her upper extremity strength.
Your assistance in helping provide ’s needs has been very appreciated. I feel that a manual wheelchair would be of great assistance in helping her overcome the limitations of her lifelong disease.
Sincere Thanks,
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