Request an Appeal on a Notice of Adverse Benefit Determination

If you receive a Notice of Adverse Benefit Determination (also known as an NOA) letter from DDD indicating that your services have been denied, terminated, reduced, or suspended and you would like to request an appeal of this action, you must do so within sixty (60) calendar days from the date of the Notice of Adverse Benefit Determination letter. If you or your representative do not understand the Notice of Adverse Benefit Determination letter, you have the right to contact AHCCCS Medical Management.

The request for an appeal of the action may be filed, either orally or in writing, with DDD’s Office of Administrative Review:

Arizona Department of Economic Security
Division of Developmental Disabilities
Office of Administrative Review
1789 W Jefferson St.
Mail Drop 2HE5
Phoenix, Arizona 85007
(602) 771-8163 or 1 (844) 770-9500 option 3
[email protected]

DDD will delegate your appeal to your DDD Health Plan for services including:

• Physical Health Services (i.e., prescription medications, DME, dental services).
• Behavioral Health Services.
• Seriously Mentally Ill (SMI) Services.
• Nursing Facility (NF) Services.
• Habilitative Physical Therapy for Members 21 Years of Age or Older.
• Emergency Alert System (EAS).

You can continue getting services during the appeal process if:

• Your appeal involves an end or reduction of the service you are currently receiving.
• The service you are getting was authorized by the Division.
• The original authorization for the service you are getting has not expired.
• You request that the service continue.
• You file the appeal before the intended date of reduction/termination, or you request the appeal within 10 calendar days of the mailing of the notice, whichever is later.

You will continue to get your services until you withdraw the appeal. You will not continue getting services during the appeal process if:

• You withdraw the appeal.
• You have not requested a hearing within 10 calendar days of the date we sent the appeal decision to you.
• You have not requested that the services continue when you requested the hearing.
• AHCCCS issues a hearing decision against you.
• The time limits of a service authorization have been met.

We will consider your appeal and issue a written decision within 30 calendar days unless more time is needed. You may be required to pay the cost of services provided during the appeal process if you lose the appeal.

If the appeal is denied, the member may go to the next step of the Appeals Process. The next step is for the member to request a hearing. The hearing is called a state fair hearing. A state fair hearing is the last step in the Appeals Process.

Expedited Appeals

You may ask for a faster review if:

• Your life or health could be in danger.
• You are not able to meet, keep, or get back to how you are able to do things by waiting 30 calendar days for a decision.

If DDD or your DDD Health Plan agrees to make a faster decision, a decision will be made in 72 hours. If the request is denied for a faster decision, you will get a phone call with a follow-up letter in two working days. The letter will tell you that you will receive a decision in 30 calendar days.

If you are unhappy with this decision, you may call the DDD Customer Service Center at 1-844-770-9500 option 1 or your DDD Health Plans’ customer service department.

Appeals for Serious Mental Illness (SMI)

SMI Determination Appeal Process

Members seeking a serious mental illness (SMI) designation and members who have been determined to have a serious mental illness designation can appeal the result of the determination.

Solari will send a letter by mail to let the member know the final decision on their SMI determination. This letter is called a Notice of Decision. If Solari finds the member is not eligible for SMI services, the letter will tell why. To file an appeal, members can call Solari at
1-855-832-2866 within 60 calendar days from the date on the Notice of Decision letter.

SMI Treatment Appeal Process

Persons who have a serious mental illness (SMI) designation can also appeal parts of their behavioral health treatment plan including:

• A decision regarding fees or waivers.
• The assessment report and recommended services in their PCSP or individual treatment or discharge plan.
• The denial, reduction, suspension or termination of any service that is a covered service funded through Non-Title XIX/XXI funds.*
• Capacity to make decisions, need for guardianship or other protective services or need for special assistance.
• A decision is made that the member is no longer eligible for SMI services.
• A PASRR determination in the context of either a preadmission screening or an annual resident review, which adversely affects the member.

To file an appeal related to any behavioral health services, you must call or send a letter to your DDD Health Plan or the Tribal Health Program (THP). If you or your representative still do not understand the Notice of Adverse Benefit Determination letter, you have the right to contact AHCCCS Medical Management.

If you file an appeal, you will get written notice that your appeal was received within 5 business days of receipt. You will have an informal conference with the DDD Health Plan or DDD Office of Administrative Review within 7 business days of filing the appeal.

An informal conference will be scheduled. This conference must happen at a time and place that is convenient for you. You have the right to have a designated representative of your choice help you at the conference. You and any other participants will be told the time and location of the conference in writing at least two working days prior. You can participate in the conference over the telephone. If the appeal is resolved to your satisfaction at the informal conference, you will:

• Get a written notice that describes the reason for the appeal.
• The issues involved.
• The resolution achieved.
• The date that the resolution will be implemented.

The next step is a second informal conference with AHCCCS if there is no resolution during this informal conference. You can waive the second level informal conference. Your DDD Health Plan or the DDD Office of Administrative Review will help you file a request for State Fair Hearing at the end of the first informal conference. You will be given information that will tell you how to request a State Fair Hearing if there is no resolution during the second informal conference. The AHCCCS Office of the General Counsel handles requests for State Fair Hearings upon the conclusion of second-level informal conferences. If you file an appeal, you will continue to get any services you were already getting unless:

• A qualified clinician decides that reducing or terminating services is best for you.
• You agree in writing to reduce or terminate services.

Expedited Appeals

For an appeal that needs to be expedited, you will get written notice that your appeal was received within 1 business day of receipt. The informal conference will occur within 2 business days of filing the appeal.

You cannot be charged for service received under SMI funding regardless of the result of the appeal.

Requesting a State Fair Hearing

If you disagree with the appeal decision, you may request a state fair hearing. AHCCCS will make the final decision about your appeal. You must file a written request for a hearing with the entity that sent you the Notice of Appeal Resolution, the DDD Office of Administrative Review or your DDD Health Plan, within 90 calendar days from receipt of the appeal decision. If it is decided that the decision was correct, you may be responsible for payment of the disputed services you received while your appeal was being reviewed.

If you do not receive a written appeal decision within 30 calendar days, you have the right to file a request for a hearing with AHCCCS. The written request for a hearing must state the issue that is being appealed.