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«Member Handbook: Integrated Health Services For Physical and Behavioral Health Services Amerigroup Louisiana LA-MHB-0018-16 05.16 1-800-600-4441 (TTY ...»

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Do you have questions about the advance directive for mental health treatment? Call the Mental Health Advocacy Service at 1-800-428-5432.

GRIEVANCES AND MEDICAL APPEALS

If you have any questions or concerns about your Amerigroup benefits, please call Member Services at 1-800-600-4441 (TTY 711). You can also write to us.

Grievances If you have questions or concerns about your quality of care, try to talk to your PCP first. If you still have questions or concerns with our services, our network providers, or things like rudeness of a provider or an Amerigroup associate, call us. We can help you file a grievance. You will not be treated differently for filing a grievance.

If your problem has to do with a denial of your health care benefits, you or a representative of your choice need to file an appeal instead of a grievance. See the next section on Medical Appeals to learn more.

Filing a grievance with Amerigroup Member Services will be happy to help you prepare and submit your grievance. You or a representative of your choice can call, fax, mail or file in person within 30 calendar days of the date you were aware of

the problem:

 Call Member Services at 1-800-600-4441 and file a grievance orally or ask for help with filling out a grievance form; include information such as the date the problem happened and the people involved  File your grievance by fax to 1-888-708-2584

Send your letter to or visit in person:

Grievance Department Amerigroup Louisiana, Inc.

3850 N. Causeway Blvd., Ste 600 Metairie, LA 70002

–  –  –

If your grievance is urgent, we will respond within 72 hours of when you tell us about it. You may ask us to extend the grievance process for 14 calendar days if you have more details that we should see.

Medical appeals There may be times when we say we will not pay for all or part of the care your provider recommended. If we do this, you (or your provider on your behalf and with your written consent) can appeal the decision.

A medical appeal is when you ask Amerigroup to look again at the care your provider asked for and we said we will not pay for. You must file for a medical appeal within 30 calendar days of the date on our first letter that says we will not pay for a service.

A medical appeal can be filed by:

 You  Your representative or a person helping you  Your PCP or the provider taking care of you at the time If you want your PCP to file an appeal for you, he or she must have your written permission, unless you are asking for an expedited appeal.

To continue receiving services that we have already approved but may be part of the reason for your

appeal, you or your provider must file the appeal:

 Within 10 calendar days from the date on the notice to you to let you know we will not pay for the care that has already been approved or  Before the date the notice says your service will end

You can appeal our decision in two ways:

1. You can call Member Services toll free at 1-800-600-4441. If you call us, we will send you a letter to let you know we got your request for an appeal. We will include an appeal form for you to complete. Let us know if you want someone else to help you with the appeal process, such as a family member, friend or your provider.

2. You can send us a letter or the appeal form to the address below.

- Include information such as the care you are looking for and the people involved.

- Have your doctor send us your medical information about this service.

Central Appeals Processing Amerigroup Louisiana, Inc.

P.O. Box 62429 Virginia Beach, VA 23466-2429 When we get your appeal, we will send you a letter within three business days.

The letter will let you know we got your appeal.

56 LA-MHB-0018-16 Updated 05/16

After we receive your appeal:

 A different provider than the one who made the first decision will look at your appeal.

 We will send you and your provider a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal. This letter will:

- Let you and your provider know what we decide

- Tell you and your provider how to find out more about the decision and your rights to a fair hearing

If you have more information about your appeal:

 You may ask us to extend the appeals process for 14 days if you know more information that we should consider  We will let you or the person you asked to file the appeal for you know in writing the reason for the delay You may also ask us to extend the process if you know more information that we should consider.

After you have gone through all of the Amerigroup appeal process, you may ask the state for a state fair hearing. See the State fair hearings section for more details.

Expedited appeals If you or your provider feels that taking the time for the standard appeals process, which is usually 30 calendar days, could seriously harm your life or your health, we will review your appeal quickly. We will call you and let you know the answer to your expedited appeal. We will also send you a letter. We will do this within three calendar days.





If we or your provider does not feel your appeal needs to be reviewed quickly, we will:

 Call you right away to let you know your appeal does not meet the criteria for an expedited review  Send you a letter within two calendar days to let you know that your appeal will be reviewed within 30 calendar days If the decision on your expedited appeal upholds our first decision and we will not pay for the care

your doctor asked for, we will call you and send you a letter. This letter will:

 Let you know how the decision was made  Tell you about your rights to request a state fair hearing Payment appeals A payment appeal is when your provider asks Amerigroup to look again at the service we said we would not pay for. Your provider must ask for a payment appeal within 30 days of receiving the EOB.

If you receive a service from a provider and we do not pay for that service, you may receive a notice from Amerigroup called an Explanation of Benefits (EOB). This is not a bill. Some reasons we may not

pay for a service:

 It is not a covered service  Prior approval was not received  /t wasn’t deemed medically necessary If you ask for a service that is not covered by Medicaid, you will have to pay the bill.

–  –  –

The provider, health care place or person who gave you this service will get a notice called an explanation of payment.

If you receive an EOB, you do not need to call or do anything at that time, unless you or your provider wants to appeal the decision.

To file a payment appeal, your provider can mail the request and medical information for the service to:

Provider Payment Dispute Amerigroup Louisiana, Inc.

P.O. Box 61599 Virginia Beach, VA 23466-1599 Continuation of benefits If you request to continue your benefits during the appeal process, we will continue coverage of your

benefits until one of the following occurs:

 You withdraw your request for an appeal.

 An appeal decision is reached and is not in your favor.

 The approval ends or the approved service limits are met.

If a decision is made in your favor as a result of the appeal process, we will:

 Start to cover services as quickly as you have need for care and no later than 10 calendar days from the date we get written notice of the decision  Approve and pay for the services we denied coverage of before You may have to pay for the cost of any continued benefit if the final decision is not in your favor.

State fair hearings After you have gone through all of the Amerigroup appeal process, you have the right to ask for a state fair hearing. You must ask for a state fair hearing within 30 calendar days from the date on the letter from Amerigroup that tells you the result of your appeal. If you wish to continue benefits during the state fair hearing, the request should be submitted within 10 calendar days from the date you get the letter from Amerigroup that tells you the results of your appeal.

You can ask for a state fair hearing in one of several ways:

 Call Member Services toll free at 1-800-600-4441. We will file it for you.

 Or send a letter to:

Division of Administrative Law - Health and Hospitals Section P.O. Box 4189 Baton Rouge, LA 70821-4189  You can also file orally by calling the Division of Administrative Law (DAL) at 225-342-5800 or fax your request to 225-219-9823.

58 LA-MHB-0018-16 Updated 05/16  Or go online to www.adminlaw.state.la.us/HH.htm to fill out a Member State Fair Hearing Request Form.

Once the DAL gets your letter:

 DAL will submit a copy of the request to the Amerigroup Appeals department  DAL will notify the Department of Health and Hospitals (DHH) that a state fair hearing request has been has been filed  Amerigroup will send DAL a copy of your appeal, the information we used to make our decision, and a copy of the notice of decision sent to you An administrative law judge at the DAL will conduct the state fair hearing. When the hearing is finished, the Secretary of DHH will report the results of the hearing decision to you, Amerigroup and DHH.

If you have any questions about your rights to appeal or request a fair hearing, call Member Services at 1-800-600-4441.

Continuation of benefits If you request to continue your benefits during the state fair hearing process, we will continue

coverage of your benefits until one of the following occurs:

 You withdraw your request for a fair hearing.

 A fair hearing decision is reached and is not in your favor.

 The approval ends or the approved service limits are met.

If a decision is made in your favor as a result of the fair hearing, we will:

 Start to cover services as quickly as you have need for care and no later than 10 calendar days from the date we get written notice of the decision  Approve and pay for the services we denied coverage of before You may have to pay for the cost of any continued benefit if the final decision is not in your favor.

OTHER INFORMATION

If you move Please call Member Services at 1-844-227-8350 right away to let us know. This way you will keep getting the information you need about your health plan.

Amerigroup will let the Louisiana Department of Health and Hospitals (DHH) know of your address change.

You will continue to get health care services through us in your current area until the address is changed. You must call Amerigroup before you can get any services in your new area unless it is an emergency.

Please also let Amerigroup know if you have a change in:

 Family size  Living arrangements  Parish of residence

–  –  –

Renew your Medicaid or LaCHIP benefits on time Keep the right care. Do not lose your health care benefits! You could lose your benefits even if you still qualify. Every year, you will need to renew your Healthy Louisiana benefits. If you do not renew your eligibility, you will lose your health care benefits.

If you have questions about renewing your benefits you can go to or call your local DHH office. We want you to keep getting your health care benefits from us as long as you still qualify. Your health is very important to us.

If you are no longer eligible for Medicaid or LaCHIP You will be disenrolled from Amerigroup if you are no longer eligible for Medicaid or LaCHIP benefits.

If you are ineligible for Medicaid for two months or less and then become eligible again, you will be re-enrolled in Amerigroup. If possible, you will be given the same primary care provider (PCP) you had when you were in Amerigroup before.

How to disenroll from Amerigroup If you do not like something about Amerigroup, please call Member Services. We will work with you to try to fix the problem.

 If you are a new member and choose Amerigroup during the initial choice period, you can switch health plans during your first 90 days of enrollment.

 If you are a current Healthy Louisiana member and wish to choose Amerigroup or a new managed care organization during your annual open enrollment, you must choose a new plan within 60 days from when you receive open enrollment information from Healthy Louisiana. If you do not choose a new plan within 60 days, you will remain enrolled in your current Healthy Louisiana plan for the next 12 months; you can only change health plans during the next 12 months if you can show good cause.

You may request to transfer to another health plan at any time. However, you may be required to provide proof or detailed information that good cause exists for your request to be processed. If you need to be disenrolled from Amerigroup at any time, please call Healthy Louisiana Enrollment Center at 1-855-229-6848, TTY 1-855-526-3346.

Reasons why you can be disenrolled from Amerigroup There are several reasons you could be disenrolled from Amerigroup without asking to be disenrolled.

Some of these are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened.

You could be disenrolled from Amerigroup if you:

 Are no longer eligible for Medicaid  Move out of the Amerigroup service area  Let someone else use your Amerigroup ID card

–  –  –

If you have any questions about your enrollment, call Member Services.

If you get a bill

Always show your Amerigroup ID card when you:

 See a provider  Go to the hospital  Go for tests Even if your provider told you to go, you must show your Amerigroup ID card to make sure you are not sent a bill for services covered by Amerigroup.

If you do get a bill, send it to us with a letter saying you have been sent a bill. Send the letter to the

address below:



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