FILING AN APPEAL

Appeal Process

What is an appeal?

You may file an appeal when you are not happy with an Optum Idaho adverse benefit determination. For example, you can file an appeal when a covered service is denied, delayed, limited or stopped.

Who can file an appeal?

You can file an appeal or you may have your provider, lawyer or a person you trust request an appeal on your behalf with your written consent. You will not be penalized for filing an appeal.

How do I file an appeal?

You can start an appeal over the phone, in writing or in person. An urgent request is when you, Optum Idaho or your provider thinks Optum Idaho needs to make a quick decision based on your health. Urgent appeals must be filed within 10 calendar days of the denial letter. You must file your non-urgent appeal within 60 calendar days of the denial letter’s date. If you wish to continue receiving services that were terminated, suspended or reduced, you must file an appeal within 10 calendar days of the denial letter. You can give Optum Idaho evidence to support your appeal in person or in writing. You can call Optum Idaho Member Services at 1-855-202-0973 Monday through Friday, 8 a.m. to 5 p.m., Mountain Standard Time, to get help.

Email: optumidaho.appeals_grievance@optum.com

Mail:
Optum Idaho
322 E. Front Street - Suite 400
Boise, ID 83702

Fax: 1-855-272-7053   |    Phone: 1-855-202-0973

Your appeal request must include:

1. Member information:

• Name
• Medicaid Identification Number
• Date of Birth
• Address

2. Your contact information

3. A copy of the denial letter

4. Any extra information that you think should be considered

5. An explanation of why you disagree with Optum’s decision and

6. Your request to continue services, if appropriate

How long will it take to process my non-urgent appeal?

Within five days of receiving your appeal, Optum Idaho will send you written confirmation that we have received your appeal.

We will tell you and your provider the outcome of the appeal within 30 calendar days. We will send you a letter telling you the outcome. If we need more time to review your appeal, we can ask Idaho Department of Health and Welfare for 14 more calendar days. If the Department agrees, we will let you know in writing.

How long will it take to process my request for urgent review of my appeal?

We will tell you and your provider the outcome of the appeal within 72 hours. We also will send you a letter telling you and your provider the outcome. Optum has the right to deny a request for an urgent review of an appeal if the appeal is determined to not be of urgent status.  If Optum Idaho denies the request for an urgent review of an appeal, the appeal will go through the non-urgent appeal process, and Optum Idaho will call the requesting party to alert them the urgent review was denied. We will also follow up in writing.

What if I am not satisfied with the appeal decision?

If you disagree with Optum’s appeal decision, you may ask for a State Fair Hearing with the Idaho Department of Health and Welfare.  This can only be done after you have appealed with Optum first.   You have 120 days from the date of Optum’s appeal resolution to file a Fair Hearing.

Will I still get my benefits during an appeal review or Fair Hearing?

You have the right to continue any service you are getting pending the decision if:

• You request an appeal review within 10 days of receiving Optum Idaho’s Adverse Benefit Determination or ask for a Fair Hearing within 10 days of Optum Idaho’s appeal resolution.
• The appeal review involves a service you were already approved to receive.
• The services were ordered by an approved provider.
• The time period of the service has not run out.

If you get services during the appeal review, but the decision is not in your favor, you may have to pay for those services.