Appeals

Division of Medicaid (Independent Assessor – Liberty, non-emergency medical transportation, EPSDT, inpatient behavioral health services, and other Medicaid benefits)
MedicaidAppeals@dhw.idaho.gov
Phone: 208-334-5747
Fax: 208-364-1811
Mail: Medicaid Appeals – IDHW, PO Box 83720, Boise, ID 83720-0009
In Person: Your Local Health & Welfare Office
Web link for processes: https://publicdocuments.dhw.idaho.gov/WebLink/Browse.aspx?id=17618&dbid=0&repo=PUBLIC-DOCUMENTS

Division of Behavioral Health
Email: APS@dhw.idaho.gov
Mail: 450 West State Street 10th floor P.O. Box 83720, Boise, ID 83720-0036
Fax: (208) 639-5741
An appeal can be requested verbally by calling 855-643-7233 and must be followed up with a written request
using one of the options listed above.

Idaho Behavioral Health Plan – Optum Idaho (Medicaid outpatient behavioral health services)
optumidaho.appeals_grievance@optum.com
Mail: Optum Idaho, 322 E. Front Street, Suite 400, Boise, ID 83702
Fax: 1-855-272-7053
Member Services: 1-855-202-0973
Appeals Process: https://www.optumidaho.com/content/ops-optidaho/idaho/en/members/rights—responsibilities.html

Division of Welfare/Self-Reliance (Eligibility for Medicaid and other benefits)
MyBenefits@dhw.idaho.gov
Phone: 877-456-1233
Fax: 866-434-8278
Mail: Self-Reliance Programs, PO Box 83720, Boise, ID 83720-0026
In Person: Your Local Health & Welfare Office
Web link for processes: https://healthandwelfare.idaho.gov/appeals-and-fair-hearings

Idaho State Department of Education
info@sde.idaho.gov
Mail: Special Education Dispute Resolution Idaho State Dept. of Education P.O. Box 83720  Boise, ID 83720-0027
Phone: (208) 332-6914 or (800) 432-4601
TT:  (800) 377-3529
Fax: (208) 334-2228
Dispute Resolution Process: https://www.sde.idaho.gov/sped/dispute/

An appeal is a written or verbal request to the State or its contractors, such as Medicaid or the Idaho Behavioral Health Plan, to review and change a decision made about your youth’s care.

An Adverse Benefit Determination (ABD) letter is sent by Optum when they:

• Denies (turns down) services or approves fewer services than you or your provider wanted
• Reduces, suspends, or terminates a previously approved service
• Denies part of or all of a payment to your provider

The ABD letter also explains the decision that was made, your right to appeal, and your right receive information used in making the decision.

An ABD letter may also be called a notice of decision or notice of action.

• A denial or termination of Medicaid eligibility
• A denial, reduction, or termination of Medicaid funded services or supports (including EPSDT determinations)
• A Medicaid benefit determination made by the Idaho Department of Health and Welfare or the independent assessment contractor, Liberty Healthcare, that a youth does not meet the following criteria for serious emotional disturbance (SED):

                 ◦ A functional impairment identified by the Child and Adolescent Needs and Strengths (CANS) assessment

                 ◦ A mental health diagnosis identified by a Comprehensive Diagnostic Assessment (CDA)

• Failure to provide YES services or supports the youth is entitled to under Appendix C of the Jeff D. Settlement Agreement: Objective-C-IAP.pdf (idaho.gov)
• When requests for eligibility or services are not acted upon with reasonable promptness

Individuals who disagree or are not satisfied with a written notice of decision made by the Department of Health and Welfare or its contractors. If an individual has not received a written notice of decision following a verbal notice of decision within a reasonable time, an appeal can be submitted. The Department of Health and Welfare’s contractors include Optum (the Idaho Behavioral Health Plan), Liberty (Independent Assessments), and MTM (Non-Emergency Medical Transportation).

Yes, an attorney, community advocate, or any person you choose that has your permission may represent you at any point in an appeal. You are responsible for any fees charged by the person representing you.

A family member, a provider, or someone else who has permission from the youth and/or family to act on their behalf.

You can submit an appeal in person, via a website, fax, telephone, mail, or e-mail. Contact information for submitting an appeal can be found on your Notice of Decision or in the Appeals Contacts section of the YES website appeals webpage. The appeal form can be found here: Fair Hearing Request (idaho.gov)

You can submit information to support why you think the decision should be changed. It is not required to submit this information. Examples include:

• A copy of the “notice of decision” or “adverse benefits determination” letter – although it is not necessary or required for an appeal
• Medical/behavioral health provider records and hospital records
• An explanation of why you disagree with the decision and what services you insist are medically necessary to address the needs of the youth
• Medical referrals
• Letters from the treating providers
• Emails

Youth and their families have the right to request a copy of all documentation used in making decisions and/or their entire record on file.

• You can request any records the Department of Health and Welfare’s contractor used in making a decision by contacting them directly and requesting it. Contact information will be on the decision letter you received.
• You can also submit a public records request to the Department of Health and Welfare by emailing PRR@dhw.idaho.gov. A youth that is 14 years old or older must sign the request in addition to their guardians. Please note, the Public Records Request unit tracks all requests for personal records, but they are not public records requests. More information about how to request records can be found at the Public Records Request webpage: https://healthandwelfare.idaho.gov/news-notices/public-records-requests.
• You may also request records from your providers. If you are having difficulty requesting this information, the Department or its Contractors may be able to help you.

• If you are on Medicaid and are already receiving services that have been reduced or denied, you may request to continue to receive these services while you are waiting for an appeal decision. This is called “Continuation of Benefits.”
• You must submit an expedited or urgent appeal within 10 days from the date on the notice of decision. If the denial you are appealing is upheld, you may be responsible for the cost of the services.

• You have 60 days from the date Optum makes a decision on a requested service to file an appeal.
• If you are not satisfied with Optum’s appeal decision, you have 120 days from the date Optum makes an appeal decision to submit an appeal to the Department of Health and Welfare.

• You have 28 days from the postmark date of the notice of decision to submit an appeal for denial of medical services and supports, transportation, independent assessment, hospital or residential behavioral health care, pharmacy, and any other medical decisions.

• You have 30 days from the postmarked date of the notice of decision to submit an appeal for a denial for or change to your youth’s Medicaid eligibility (for example, losing Medicaid coverage).

• You can request an Expedited or Urgent appeal with Optum if you feel that waiting up to 30 days for an appeal decision could jeopardize the youth’s life, health, or ability to regain maximum functioning. Optum will decide if your appeal meets urgent criteria. If your provider supports the urgent request Optum will automatically grant the urgent appeal. If the urgent appeal is not granted, Optum will notify you and give you a decision within 30 calendar days.
• You can submit letters from treating providers and other information to establish the need for an Expedited or Urgent appeal.
• When you submit your expedited/urgent appeal use the contact information on the notice of decision letter.

• You can use the Medicaid Appeal Request Form, check the box in Section 3 to indicate that you are requesting an expedited appeal. If you are submitting your appeal in any other way, be clear that you are asking for an expedited, urgent, or fast appeal.
• When you submit your expedited/urgent appeal follow the instructions on the Medicaid Appeal Request Form.

• For a standard appeal submitted to Optum, a decision will be made within 30 calendar days.
• For an expedited/urgent (fast) appeal, a decision will be made within 72 hours.
• If you submitted a standard appeal to the Department and the appeal goes to a State Fair Hearing, the time to make a decision may be longer. Once the hearing is held, the Hearing Officer will make a decision within 30 calendar days for a standard appeal and as soon as possible for an expedited appeal.

• For an appeal submitted to a contractor, the contractor will review the documents submitted to support your appeal, all documents in your case that were used to make the decision that you are appealing, and criteria for the service that was requested. A different person than the one who made the original decision will conduct this review. The contractor will communicate the outcome to you in writing within 30 days. If you disagree with the outcome of this appeal, you can follow instructions on your appeal resolution letter to submit an appeal to the Department and request a State Fair Hearing.
  
  
• For an appeal submitted to the Department, the Department will first conduct an internal review (sometimes called an “informal review”) of the appeal. The internal review includes reviewing all the documents submitted to support your appeal, all documents in your case file that were used to make the decision you are appealing, and criteria for the service that was requested. A different person than the one who made the original decision will conduct this review. The Department will communicate with you about the preliminary outcome of the internal review within the 30 days. 

• If you disagree with the Department’s internal review, a State Fair Hearing will be scheduled with the Fair Hearing Unit of the Attorney General’s Office at the earliest available date. State Fair Hearings are all telephonic (over the phone). The date of the hearing is selected by the Hearing Officer and sent to you via mail or email with a date, time, and call-in information. If the date or time do not work for you, please follow the instructions on your Notice of Scheduling to request a new date. The Notice of Scheduling will also include information on how to submit supporting documentation (called ‘exhibits’) and how to have people to support you at the hearing (called ‘witnesses’).

• At the hearing you will have the right to present witnesses and documents to support your appeal and to ask the Department’s witness questions about the decision. After the hearing, the Hearing Officer will issue a decision in no more than 30 calendar days. More information on the hearing process is available on the YES appeals webpage: https://yes.idaho.gov/appeals/

• If you would like copies of any of the information and documentation used in the internal review or used in making the decision, you may request them from the Department or the contractor. Please see the Frequently Asked Question titled, “How do I request records used in making the decision that I want to appeal?”

• If you submitted an appeal to Optum and you have not received a notice of decision on your appeal within 30 days, you may submit an appeal to the Department without waiting for a decision from Optum.

• If you submitted an appeal to the Department or another contractor (Liberty, MTM, etc.), please reach out directly to the contact you filed your appeal with to inquire about the status of your appeal. Contact information can be found on your notice of decision letter or in the Appeals Contacts section of the YES website appeals webpage: https://yes.idaho.gov/appeals/

Please reach out directly to the contact you filed your appeal with and inquire about the status of your appeal. Contact information can be found on your Notice of Decision or in the appeals contacts section of this webpage: https://yes.idaho.gov/appeals/

• If the deadline for submitting for an appeal is coming up and you do not have information you requested from your provider, you can file your appeal without it. The documentation can be submitted after you request an appeal.
• If you are having trouble getting the supporting documents you requested from your provider, notify the Department of Health and Welfare and they can request that documentation for you.
• If the date for a State Fair Hearing is coming up and you do not have the paperwork or documentation you need to submit to support you during the hearing, contact the Fair Hearing Unit by emailing them at: hearing.officer@ag.idaho.gov or call them at: (208) 334-4555. They may suggest you work with the Department of Health and Welfare to reschedule the hearing to a later date. When rescheduling a hearing, the Fair Hearing Unit will request you and the Department of Health and Welfare submit 3 dates and times that you agree work for both of you. They will select 1 time out of those and reschedule the hearing.

• To ensure your standard appeal request was received, please wait five (5) business days to allow the agency you filed the appeal with to document and begin the appeal process.
• To ensure your expedited appeal request was received, please contact the agency you filed the appeal with the next business day.

• No. An appeal cannot be submitted due to inability to locate a provider for services.
• If you can’t find a provider or access a recommended service, please contact Optum to help you locate a service provider or alternative service.
• If Optum cannot find you a provider or alternative service, you can file a complaint with Medicaid using the form on the YES website at Youth Empowerment Services Concern and Complaint Form (keysurvey.com) or by emailing YES@dhw.idaho.gov.  

• If you feel you are being retaliated against or if you have any other concerns, you are free to submit your questions or file a complaint directly by using this link: Youth Empowerment Services Concern and Complaint Form (keysurvey.com) or by emailing YES@dhw.idaho.gov. You can submit your questions or complaint anonymously.
• You can also reach out to Families and Youth of Idaho (FYIdaho) for support in filing a complaint or navigating the appeals process by emailing them at: support@FYIdaho.org.

• Any of the contacts in the appeals contacts section of the YES webpage can help you with the appeals process: https://yes.idaho.gov/appeals/
• These contacts include The Department of Health and Welfare’s divisions of Medicaid, Behavioral Health, and Welfare/Self-Reliance, and Optum.
• You may also contact Families and Youth of Idaho (FYIdaho) for support in filing an appeal or understanding the appeals process by emailing them at: support@FYIdaho.org

The complete appeal and fair hearing process can be found in the YES Practice Manual Guide to YES: A Practice Manual | YOUTH EMPOWERMENT SERVICES (idaho.gov)

• The Department of Health and Welfare ‘s Contested Case Rules: IDAPA 16.05.03

IDAPA 16 – Department of Health and Welfare.book (idaho.gov)

• The federal Managed Care Organization grievances & Appeals: eCFR :: 42 CFR Part 438 Subpart F — Grievance and Appeal System
• The federal Medicaid Regulations: 42 U.S.C. section 431.200 Fair Hearings

 eCFR :: 42 CFR 431.200 — Basis and scope. 

• The Jeff D YES Due Process Protocol: YES Due Process Protocol (idaho.gov)