Medical Appeals & Grievances

You may ask for an appeal when we make an adverse benefit determination. If we make an adverse benefit determination, we will send you and your doctor a letter telling you why. This letter will also tell you how to file an appeal.

You can ask for an appeal of coverage for a medical service that:

• Was denied.
• Was changed.
• Was approved and then stopped.
• Was not given in a timely manner.

You can also ask for an appeal if we denied your request to dispute financial liabilities, such as copays, premiums, deductibles and coinsurance.

Who Can File An Appeal

You, your doctor or someone you choose to act for you can ask for an appeal. This person can be anyone you choose, including a lawyer. This person is called an authorized representative.

If you want a representative to ask for an appeal for you, you must submit a Member Appeal Representative Form or send us a letter. If you send us a letter, be sure to: 

• Write the date on the letter.
• Write a full name of your representative.
• Tell us you want this person to file an appeal on your behalf.
• Sign the letter.

A parent, legal guardian or conservator may file an appeal for a member who is:

• A minor under the age of 16. Minors ages 16 or older will need to submit a Member Appeal Representative Form to have someone act on their behalf.
• Incompetent, or not able to act for mental reasons.*
• Incapacitated, or not able to act for physical reasons.*
  *Documentation such as a medical power of attorney or incapacitated dependent form required.

How And When To File An Appeal

You or your representative may ask for an appeal within 60 days of our adverse benefit determination.

You can ask for an appeal one of these ways:

• Call Customer Service at 866-781-5094 (TTY: 866-773-9634)
• Fill out and submit the Member Appeal Form. 
• Write a letter or fill out the appeals form and send it to us at:

Healthy Blue — Appeals
P.O. Box 100215
Columbia, SC 29202-3215

Once you start an appeal, be sure to give us any information you think we should have to review your appeal. If you think you need more time to do this, you can ask us to add up to 14 calendar days to your appeal time.

Customer Service staff can help you file your appeal or handle your request for more time to gather and send us your information. If you need an interpreter, we will provide one at no cost to you.

When To Expect A Response

Within five (5) days of getting your appeal, we will send you a letter. It will tell you we received your appeal request. This letter will also tell you or the person acting for you of your right to give us more information in writing or in person within seven (7) days of the letter. It will also have a free copy of your case file. This file will have your health records and other materials or details we used to make our adverse benefit determination. Your case file includes:

• Your health records.
• Other documents and records used in the original denial.
• New or more information that we will use in the appeal.

Expedited (Rush) Appeals

You can ask for a rush appeal if you think waiting 30 calendar days for our decision may harm your health. To ask for a rush appeal, you may call us, fax us or mail us a letter. Be sure to tell us why you think waiting 30 calendar days will harm your health.

An appeals nurse will review your request for a rush appeal. If that nurse thinks waiting 30 calendar days will harm your health, we will:

• Call you within 72 hours to tell you what we decided.
• Mail the decision to you.

If the appeals nurse thinks waiting 30 calendar days will not harm your health, we will call or fax you to tell you that. We will also send you a letter within two calendar days. The letter will let you know we will complete your appeal as fast as we can within 30 calendar days.

You or your representative may file a grievance if you disagree with the decision to change the rush appeal to a regular appeal. 

Standard and Expedited Appeal Extensions

We also may add up to 14 calendar days to your appeal time if it is in your best interest to do so. 

We will call you or the person acting for you and send a letter within two calendar days of making our decision to extend the time frame. The letter will explain: 

• The reason for the delay. 
• How you may file a grievance within two calendar days of getting this letter if you disagree with our decision to add more time to our review. 

We will resolve the appeal as quickly as your health condition requires and no later than the date the extension ends. 

State Fair Hearing

If you are not happy with the appeal decision, you or the person acting for you has the right to ask for a state fair hearing with SCDHHS.

You may ask for a state fair hearing within 120 calendar days from the date of the appeal notification letter. To ask for a state fair hearing, you or the person you choose to act for you can:

• Go to www.scdhhs.gov/appeals*
• Mail a written request to:

Division of Appeals and Hearings
1801 Main St.
P.O. Box 8206
Columbia, SC 29202

• Fax your request on 803-255-8206

• Email your request to appeals@ scdhhs.gov.

For help or questions, call 803-898-2600 or 800-763-9087.

_{*This links to a third-party website. That organization is responsible for the content and privacy policy on its site.}

Keeping Your Benefits During Your Appeal or State Fair Hearing Process

You may keep your previously approved benefits for the appealed service while Healthy Blue reviews your appeal and while you wait for your state fair hearing. All of these things must happen: 

• You request that your benefits continue within ten (10) calendar days from the date on your adverse benefit determination notice. 
• The appeal has to do with the coverage for a service that has been delayed, reduced or stopped after it was approved. 
• An approved provider ordered the service. 
• The original period covered by the original authorization has not expired. 
• You asked to extend your benefits. 

They will be in effect until one of these happens: 

• You stop your appeal or hearing request. 
• Ten (10) days have passed after we sent you a letter with our decision to uphold the first denial, unless you asked for a state fair hearing within that 10-day period. 
• A state fair hearing officer upholds our denial. 
• This time frame of an approved service has been met. 

If the results of the appeal is the same as the original denial decision, you may have to pay for the costs of the services you were given while the appeal was pending. 

Download Appeals Forms