Filing an Appeal

If you don’t agree with a decision, or an adverse benefit determination, we make about services or payment, you have the right to appeal. An appeal is when you request Absolute Total Care to review an adverse benefit determination made by Absolute Total Care. This review makes us look again at the adverse benefit determination.

An adverse benefit determination is when Absolute Total Care:

• Denies or limits a requested service,
• Reduces, suspends, or terminates a service that has already been approved,
• Denies payment for a service,
• Fails to provide services in a timely manner, as defined by the State,
• Fails to act within the timeframes provided,
• Denies a member, who is a resident of a rural area where there is only one MCO, request to exercise his or her right to obtain services outside the Absolute Total Care network, or
• Denies a request to dispute a financial liability, including cost-sharing, copayments, premiums, deductibles, and coinsurance.

You will know that Absolute Total Care made an adverse benefit determination because we will send you an Adverse Benefit Determination Notice. If you do not agree with the adverse benefit determination, you may request an appeal. The Adverse Benefit Determination Notice will explain the appeals process and includes a copy of the Appeal Form. You may also find the form on our Member Handbooks and Forms page.

An appeal may be filed within 60 calendar days from the date on the Adverse Benefit Determination Notice. If you need assistance with your appeal please call Absolute Total Care at 1-866-433-6041 (TTY: 711) and we will assist you in filing your appeal. This includes providing assistance with accessing interpreter services and hearing impaired services, if needed, at no cost to you.

Who can file an appeal?

• An Absolute Total Care member or a member’s authorized representative.
• An authorized representative is a person or a provider a member gives the right to act on their behalf.
• The member can give permission for a person or a provider to act on their behalf in writing or by completing the Appointment of Authorized Representative Form found on the Member Handbooks and Forms page.

There are two kinds of appeals:

• Standard Appeal – We will give you a written decision within 30 calendar days from the date of receipt of your request.
• Expedited Appeal –You can ask for an expedited (or fast) appeal if you or your doctor believe your health could be seriously harmed by waiting up to 30 calendar days for a decision. We will give you a written decision within 72 hours from the date of receipt of your request. We will also make efforts to contact you and your provider by phone of our decision.

Contact our Grievance and Appeals Coordinator at 1-866-433-6041 (TTY: 711) if you think you need an expedited appeal. An expedited appeal does not require written confirmation.

If your request for an expedited appeal is denied we will contact you and your provider promptly by phone. We will also send you a written notice within two calendar days of receiving your expedited appeal request. Absolute Total Care will let you know that your request will be processed as a standard appeal and your right to file a grievance if you disagree with the decision. We will then give you a written decision within 30 calendar days of the date of the appeal request.

Absolute Total Care may extend the timeframe to resolve a standard or an expedited appeal up to 14 calendar days if you or your authorized representative request an extension, or Absolute Total Care can demonstrate that there is a need for additional information that is in the your best interest. You will be notified in writing of the reason for the additional time to resolve the issue.

If an extension is made to your appeal, we will contact you and your provider promptly by phone to let you know of our decision. We will also send you a letter within two calendar days that includes the reason for the extension and your right to file a grievance if you disagree with our decision.

Your appeal will be reviewed by a medical director or appropriately licensed professional who was not involved in the prior decision, does not report to the prior decision-maker, and will make the final decision for your appeal request.

You have the right to present evidence and facts in person, in writing or by phone.

How to file an appeal

• Call Member Services at 1-866-433-6041 (TTY: 711).
• Mail, email or fax a completed Appeal Form or a letter about your appeal. You can obtain an Appeal Form from the Member Handbooks and Forms page. A copy of the Appeal Form is also included with your Adverse Benefit Determination Notice. Be sure to include:
  • Your first and last name
  • Your Absolute Total Care Member ID card number
  • Your address and telephone number
  • The reason for your appeal

  Mail:
  Absolute Total Care

  Attn: Grievance and Appeals

  100 Center Point Circle
  Columbia SC 29210

  Fax: 1-866-918-4457
  

  Absolute Total Care will send you a letter letting you know that we received your appeal.

  You have the right to present evidence regarding your appeal in person, in writing or by phone. You also have the right to review any evidence and documents regarding your appeal in person at the Absolute Total Care office address listed above. There is a limited time to exercise these rights for expedited appeals.

  Member Rights to State Fair Hearing

  If you are still not satisfied with the final decision, you or your authorized representative may file an appeal directly to SCDHHS Division of Appeals and Hearings. The request for a State Fair Hearing must be made within 120 calendar days from the date of the Notice of Resolution letter. You can give permission for a person or a provider to act on your behalf by completing the Appointment of Authorized Representative Form on our Member Handbooks and Forms page.

  A request for a hearing must be in writing. Send this request to:

  South Carolina Department of Health and Human Services
  Division of Appeals and Hearings (Ste. 901)
  P.O. Box 8206
  Columbia, SC 29202-8206
  803-898-2600

  Who will attend the State Fair Hearing?

  A member or member’s representative will attend the State Fair Hearing. A representative from Absolute Total Care will attend.

  Continuation of Benefits While an Appeal or State Fair Hearing are Being Decided

  You may ask to keep getting care related to your appeal while we make our decision. You or your authorized representative can request to continue to receive the care within 10 calendar days of the day Absolute Total Care mails the Adverse Benefit Determination Notice or the intended effective date of Absolute Total Care’s proposed adverse benefit determination. A provider cannot request the continuation of services for you.

  Absolute Total Care must continue the benefits if:

  • The member or member's authorized representative files the appeal timely,
  • The appeal reduces, suspends, or terminates a service that has already been approved,
  • The services were ordered by an authorized provider,
  • The original period covered by the original authorization has not expired, or
  • You requested an extension of benefits timely.

  If Absolute Total Care continues or reinstates the care at your request while the appeal is pending, the care must be continued until one of the following occurs:

  • The member withdraws the appeal request,
  • Ten (10) calendar days pass after Absolute Total Care mails the Adverse Benefit Determination Notice providing the resolution of the appeal, unless the member, within the 10-day timeframe, has requested a State Fair Hearing with continuation of benefits until a State Fair Hearing decision is reached,
  • A State Fair Hearing officer issues a decision adverse to the member, or
  • The time period or service limits of a previously authorized service have been met.

  If the final resolution of the appeal decision is not in your favor, you may have to pay for the cost of the services furnished while the appeal resolution was pending.

  Ombudsman

  You have the right to be represented in the appeal process by anyone you choose, including an attorney, but representation is not required. The State of South Carolina can provide representation through its health insurance ombudsman office if you wish to use the service. To contact the service, call 803-734-5049, or mail the South Carolina Office of Ombudsman, Wade Hampton Building, 1205 Pendleton Street, Columbia, SC 29201.