WHAT DO WE MEAN BY HEALTHCARE SERVICES?
CLS advocates on behalf of individuals and families who have been denied coverage or services, or face reductions in services, through state health care insurance programs administered by the Arizona Health Care Cost Containment System (AHCCCS). These programs include: Arizona Long Term Care System (ALTCS), Medicare Cost Savings programs, the Division of Developmental Disabilities services, and behavioral health services.
Arizona Health Care Cost Containment System (AHCCCS)
Your Rights to Medical Services under the AHCCCS Managed Care Program
AHCCCS is Arizona’s Medicaid program. AHCCCS contracts with health plan contractors to provide services to enrolled members. Individuals must meet certain income and other requirements to obtain services.
AHCCCS offers several insurance programs that cover people in the following groups:
- Families with children
- Individuals and couples without children
- People who are elderly or disabled and receive SSI
- People who have a disability and need long-term care
- Pregnant women
- People who need help to pay for Medicare costs
- Working people who have a disability
- Women who want screening for breast or cervical cancer
Eligibility for AHCCCS is determined by various agencies. For example, pregnant women and adults with children generally apply for AHCCCS through the Department of Economic Security or online at opens in a new windowwww.healthearizonaplus.gov. Eligibility for programs like KidsCare, Arizona Long Term Care Services (ALTCS), SSI, MAO, and Medicare Cost Sharing is handled by AHCCCS itself. Each eligibility group has its own income and resource criteria.
When you are determined eligible for AHCCCS, you are enrolled in the AHCCCS health plan of your choice. “Medically necessary” services are covered by the AHCCCS health plans, including:
- Doctor visits
- Preventive care
- Hospital services
- Prescriptions/medical supplies
- Labs and x-rays
- Emergency care
- Mental health services
Children under 21 also receive:
- Dental exams and treatment
- Eye exams and glasses
- Hearing tests and hearing aids
- Nutritional information
Answers to the most frequently asked questions.
What are "medically necessary" services?
Services or equipment are medically necessary if they prolong life, prevent or treat diseases, disability, or other adverse health conditions. If a service is medically necessary for a child, it may be covered by AHCCCS even though it may not be covered for an adult.
Why are some medical services denied?
The health plan may deny a service (i.e., treatment, prescription, medical equipment) that is not supported by proof that it is medically necessary. Make sure your doctor sends a letter to the health plan explaining the reasons the services are medically necessary. The letter should include a description of your medical condition and how the service will prevent or treat your condition. The letter should also explain what may happen if you do not get the service. The opens in a new windowArizona Center for Disability Law has an excellent guide for your doctor on how to write a letter of medical necessity.
If the service is denied, you should ask your doctor to call and speak with the Medical Director at your health plan who made the decision. By doing so, your doctor may be able to convince your health plan to approve the service.
What if a prescribed medication is not covered by your health plan?
If your doctor prescribes a medication that is not covered on the health plan’s drug list, called a formulary, it may be denied. Ask your doctor if there is another drug on the formulary that you can use. If you have used medications on the formulary that didn’t help you, ask your doctor to tell the health plan about these prescriptions and why they did not work for you.
What if my health plan denies a new service or stops a service I am currently receiving?
If the request for a new service or prescription is denied, or a current service stopped, you and your doctor will receive a Notice of Action from your health plan explaining the reasons for the denial. If you disagree with your health plan’s decision, you may file an appeal within 60 days. The Notice of Action sent by your health plan will explain your appeal rights.
If you are being denied a service that you are currently receiving (not a new service), you can request that the service be continued during the appeal process. To do this you must make your request in writing to the health plan within 10 days of receiving the Notice of Action. If your appeal is unsuccessful, the health plan may recover the cost of the services furnished to you during the appeal process.
How do I appeal the denial of a service or prescription?
You can ask the health plan to review the decision by filing an appeal with the health plan within 60 days from the date of the Notice of Action. You can call the health plan to request an appeal, but it is best to file an appeal in writing. Your letter should explain the reason(s) you disagree with the health plan’s decision. Keep a copy of your letter for your records. You should also attach any documentation that shows the service being requested is medically necessary, such a letter from your doctor that explains your need for the service. You should receive a written Notice of Appeal Resolution within 30 days after the health plan receives your appeal.
If your appeal is denied, you can request a State Fair Hearing. You must request the hearing in writing and the health plan must receive it no later than 30 days after the date of the Notice of Appeal Resolution. However, some health plans may provide a longer time in which to appeal. Be sure to check the notice for the appeal deadline. You will receive a Notice of Hearing which will tell you the day, time and location of the hearing. You will be allowed to present documents and witnesses to prove the medical necessity of the service that your doctor is requesting. A judge will make a recommended decision to AHCCCS and the Director of AHCCCS will make a final decision.
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