Stage
1 – Informal Internal appeal. To initiate this level
of appeal, call the MCO and ask to speak to the medical
director or physician who made the decision regarding
your case; state that you want to appeal the decision;
and that you want reconsideration of the decision (provide
as much information as possible as to why the decision
should be reconsidered). The MCO has 5 business days,
or 72 hours (emergencies), to respond to your appeal.
If the MCO continues to deny or restrict coverage, it
must inform you in writing of their decision and how to
proceed to a Stage 2 appeal.
Stage
2 – Formal Internal appeal. At this stage of appeal,
your appeal must be reviewed by physicians who are trained
to practice in the same specialty and would typically
manage the case you are appealing. This appeal must be
promptly filed in writing and should include what you
want, along with supporting documentation. Once your appeal
is received, you are entitled to a decision within 20
business days, or 72 hours (emergencies). If the MCO needs
more than 20 days to complete their review, it must obtain
permission from the State. If the Stage 2 appeal is denied,
the MCO must give you written notice detailing the reasons
for denial and provide an explanation of your right to
a Stage 3 appeal. If at any time the MCO fails to comply
with the Stage 2 appeal requirements, you may proceed
directly to Stage 3.
