Appeals

What is an appeal?

Whenever we make a coverage decision or take an action that you disagree with, you may file an appeal. If we deny, reduce, suspend, or end your health care services, we must send you a written notice within at least 10 calendar days before taking the action. The written notice must explain the reason for the "action," specify the legal basis that supports it, and include information about the appeal process.

If you decide to appeal our decision, it is very important to review the written notice carefully and follow the deadlines for the appeal process.

Actions that may be appealed include:

  • A decision to deny or limit a requested health care service or request for prior authorization in whole or in part.
  • A decision to reduce, suspend, or end health care service that you are getting.
  • A decision to deny a member request to dispute a financial liability, including cost- sharing, copayments, and other enrollee financial liabilities. This includes denial for payment of a service, in whole or in part.
  • When a member is unable to access health care services in a timely manner.

You have the right to file an appeal even if no notice was sent to you by our plan. If you receive a verbal denial, you should request a written denial notice and appeal after receiving the verbal and/or written denial notice if you are dissatisfied with our decision.

Levels and Types of Appeals

There are two levels of appeals, first level appeals and State Fair Hearing appeals. Within each level, there are also two types of appeals, standard and expedited. For more information about State Fair Hearing appeals, visit our section on State Fair Hearings.

To file a first level appeal:

  • You must file your standard or expedited appeal with AmeriHealth Caritas New Hampshire over the phone or in writing within 60 calendar days of the date of the plan’s written notice to you. Your oral request for a standard appeal must be followed by a written and signed appeal request from you. We can help you complete the appeal form.
  • In your signed, written appeal request:
    • Include your name, address, phone number, and email address (if you have one).
    • Describe the date of the action or notice from the plan you want to appeal, and attach a copy of the notice.
    • Explain why you want to appeal the decision.
    • If the plan’s decision was to deny, reduce, limit, suspend, or end your previously authorized benefits, indicate whether you want to have previously authorized benefits continued.
  • For a standard appeal, we will issue our written decision within 30 calendar days after receipt of your appeal request. We may take up to an additional 14 calendar days if you request the extension, or if we need additional information and feel the extension is in your best interest. If we decide to take extra days to make the decision, we will tell you in writing. If you disagree with our extension, you may file a grievance.
  • You may designate someone to file the appeal for you, including your provider. However, you must give written permission to have your provider or another person file an appeal for you.
  • If your appeal review needs to be expedited (reviewed more quickly than the standard time frame) because you have an immediate need for health services, you do not need to follow up in writing after you call us. We will let you know in writing that we received your request for an expedited appeal and will resolve your request as expeditiously as your health condition requires, but no later than 72 hours after we receive your request.

Send your written plan appeal request to:
AmeriHealth Caritas New Hampshire
PO Box 7389
London, KY 40742-7389

To file an appeal by phone, call Member Services at 1-833-704-1177 (TTY 1-855-534-6730). You can call 24 hours a day, seven days a week.

To file an appeal by fax: 1-833-810-2264.

Before and during the appeal, you or your representative can see your case file, including medical records and any other documents and records being used to make a decision on your case.

You can ask questions and give any information (including new medical documents from your providers) that you think will help us to approve your request. You may do that in person, in writing or by phone.

If you need more time to gather your documents and information, just ask. You, your provider or someone you trust may ask us to delay your case until you are ready. We want to make the decision that supports your best health. This can be done by calling Member Services at 1-833-704-1177 (TTY 1-855-534-6730) or writing to:
AmeriHealth Caritas New Hampshire
PO Box 7389
London, KY 40742-7389.

Your care while you wait for a decision

When the health plan’s decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we are making a decision on your appeal. You can also ask a trusted representative to make that request for you.

We must continue benefits at your request when the following occur:

  • Within 10 calendar days of the date you receive the notice of action from the plan or the intended effective date of the plan’s action, you file your first level appeal orally or in writing (oral appeals must be followed up in writing) AND you request continuation of benefits pending the outcome of your first level appeal, orally or in writing and;
  • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment and;
  • The service was ordered by an authorized provider and;
  • The original authorization period for the service has not expired.

To request continuation of benefits when the above conditions are met, contact:
AmeriHealth Caritas New Hampshire
PO Box 7389
London, KY 40742-7389

By phone: 1-833-704-1177 (TTY 1-855-534-6730). You can call 24 hours a day, seven days a week.

By fax: 1-833-810-2264

If at your request the plan continues or reinstates your benefits while your appeal is pending, your benefits must continue until one of the following occurs:

  • You withdraw your plan appeal, in writing.
  • The plan’s first level appeal decision results in an unfavorable decision for you.
  • You do not request a State Fair Hearing AND continuation of benefits within 10 calendar days of the plan notifying you of its first level appeal decision.

If the appeal decision is in your favor, the plan will pay for your services. The services will be authorized as expeditiously as your health condition requires, but no later than 72 hours from the date we reversed our decision.

If you lose your appeal and have received continued benefits, you may be responsible for the cost of any continued benefits provided by the plan during the appeal period.

If you need help with understanding the Appeals process, you can call:

  • AmeriHealth Caritas Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.
  • NH DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447) (TDD Access Relay: 1-800-735-2964), Monday through Friday, 8 a.m. – 4 p.m. ET.

If you are unhappy with the result of your appeal, you can ask for a Fair Hearing.  

Members