Grievances and appeals
First Choice cares about the health care and service you receive from our providers and us. We want to know when you are not satisfied so that we can help. If you have questions, you can always call Member Services at 1-888-276-2020.
First Choice may extend the time frame for resolving a grievance or appeal up to fourteen (14) calendar days if you request the extension or First Choice shows (to the satisfaction of the state, upon its request) that additional information is needed and how the delay is in your best interest. If First Choice extends the time frame, we will give you written notice of the reason for the delay if the extension was not requested by you. You or your authorized representative can request an extension.
A grievance happens when you are not satisfied with any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships, such as rudeness of a provider or employee, or failure to respect your member rights regardless of whether remedial action is requested.
A grievance includes your right to dispute an extension of time proposed by First Choice to make an authorization decision. A grievance may be filed at any time. As state law permits, and with your written consent, a provider or an authorized representative may file a grievance for you. A grievance can be filed over the phone by calling Member Services at 1-888-276-2020 or in writing by mailing it to:
First Choice Member Services
P.O. Box 40849
Charleston, SC 29423-0849
You have the right to send written materials that support your grievance. We will send you a letter to let you know we received your grievance. After we finish our research and within 90 calendar days of getting your grievance, we will send you another letter with the outcome.
An appeal happens when you or an authorized representative who speaks on your behalf asks First Choice to review an adverse benefit determination we have taken (as state and federal law permits, and with your written consent, a provider or authorized representative may file an appeal for you). An appeal is a request for review of adverse benefit determination. “Adverse benefit determination” means:
- The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
- The reduction, suspension or termination of a previously authorized service;
- The denial, in whole or in part, of payment for a service;
- The failure to provide services in a timely manner, as defined by the South Carolina Department of Health and Human Services (SCDHHS);
- The failure of the managed care organization (MCO) to act within the time frames provided in 42 C.F.R. § 438.408(b) (1) and (2) regarding the standard resolution of grievances and appeals; or
- For a resident of a rural area with only one MCO, the denial of a Healthy Connections MCO member’s request to exercise his or her right, under 42 C.F.R. § 438.52(b)(2)(ii), to obtain services outside the MCO’s network;
- The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.
You will receive an adverse benefit determination letter when a service has been denied or authorization limited.
You or your authorized representative are allowed up to sixty (60) calendar days from the date on the adverse benefit determination letter to file an appeal or expedited appeal. As state law permits, and with your written consent, a provider or an authorized representative may file an appeal or request a State Fair Hearing for you. However, providers cannot request continuation of benefits as specified in 42 C.F.R.§ 438.420(b)(5).
In handling your grievance or appeal, we will provide you with any reasonable assistance in completing forms and taking other procedural steps. You may present evidence in person or in writing. We will provide you and your authorized representative your case file. You can review all documents, medical records, and new or additional information used by First Choice for the adverse benefit determination. The information will be available to you free of charge and sufficiently before and during the appeals process. The review can be before and during the appeals process.
You can begin an appeal by calling Member Services at 1-888-276-2020 or in writing. If you appeal by telephone and it is not an expedited appeal, you must follow up by putting your appeal in writing. Written confirmation of all non-expedited oral appeal requests must be received by us within 30 calendar days from when we receive your oral appeal request or we may deny your appeal. We must get your appeal within 60 calendar days from the date of the notice of adverse benefit determination. Send the appeal to:
First Choice Member Services
P.O. Box 40849
Charleston, SC 29423-0849
Your standard appeal will be resolved within thirty (30) calendar days from the day we get it. If your appeal is urgent, you may call Member Services at 1-888-276-2020 and ask for an expedited (fast) appeal. A medical director will review your request. An appeal will be determined as expedited if waiting 30 calendar days may seriously jeopardize your life, physical or mental health, or ability to attain, maintain, or regain maximum function.
For expedited appeals, we will make a decision within 72 hours after we get the request. You do not need to put your expedited appeal in writing.
However, if we decide your expedited appeal request is not an expedited appeal, we will make a decision resolving your appeal within 30 calendar days from when we received your expedited appeal request; in addition, we will try to call you and send a letter within two calendar days from your request to let you know the reason for this decision to extend the time frame and let you know of your right to file a grievance if you disagree with that decision.
First Choice may extend the time frame for resolving a standard or expedited appeal up to fourteen (14) calendar days if you request the extension or First Choice shows (to the satisfaction of the state, upon its request) that additional information is needed and how the delay is in your best interest.
If First Choice extends the time frame, we will make reasonable efforts to give you prompt oral notice. Within two (2) calendar days, we will give you written notice of the reason for the extension. You can file a grievance if you disagree with the decision to extend the time frame for resolving the appeal.
The First Choice final appeal decision will be sent to you by certified mail, return receipt requested. If you do not agree with the final decision by First Choice you have the right to request a state fair hearing. You may also request a State Fair Hearing if First Choice does not follow the notice or timing requirements for appeals. With your prior written consent, you can request a representative of your choice to represent you at the State Fair Hearing.
A provider cannot require you to make him or her your representative to receive these services. Your request for a state fair hearing must be sent within 120 calendar days from the date on the resolution letter. If you feel that waiting could jeopardize your life, health, or ability to attain, maintain, or regain maximum function, you may also request an expedited (fast) State Fair Hearing. You can make the request through the SCDHHS website or send it in writing to:
South Carolina Department of Health and Human Services
Division of Appeals and Hearings
P.O. Box 8206
Columbia, SC 29202
You may call Member Services at 1-888-276-2020 to ask that your benefits continue while waiting for your appeal to be looked at. First Choice will continue your benefits if all of the following occur:
- You filed your appeal timely, within 60 calendar days from the date on the adverse benefit determination notice;
- The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
- The services were ordered by a provider;
- The original period covered by the original authorization has not expired; and
- You timely request an extension of benefits, or if state law permits, and with your written consent, an authorized representative requests an extension of benefits with the exception that providers cannot request continuation of benefits. Timely request for an extension of benefits means files for continuation of benefits on or before the later of the following:
- With 10 calendar days from First Choice mailing the notice of adverse benefit determination, or
- The intended effective date of First Choice’s proposed benefit determination.
If First Choice continues or reinstates your benefits while the appeal or State Fair Hearing is pending, the benefits must be continued until one of the following occurs:
- You withdraw the appeal or State Fair Hearing.
- You do not request a State Fair Hearing and continuation of benefits within ten (10) calendar days after First Choice sends you the notice of an adverse benefit resolution to your appeal under § 438.408(d)(2).
- A state fair hearing officer issues a hearing decision adverse to you.
If the final resolution of the appeal is adverse to you and upholds our initial adverse benefit determination, First Choice will recover the cost of the services furnished to you while the appeal was pending to the extent that they were furnished solely because of the requirements of our contract with SCDHHS, and the requirements in 42 C.F.R. Section 438.420, and in accordance with the policy set forth in 42 C.F.R. Section 431.230(b).
If First Choice or the State Fair Hearing Officer reverses a decision to deny, limit, or delay services that were not provided while the appeal was pending, First Choice will authorize or provide the services to you promptly and as fast as your health condition requires. This will occur no later than 72 hours from the date that First Choice receives notice of the reversed decision.