Either the person or the prescribing provider may appeal a denial for authorization or payment. Routine adjustments to claims are handled through the HHS Pharmacy Benefits Access Help Desk. Other appeals, administrative reviews, and due process hearing requests for services authorized and paid by CSHCN must be submitted in writing. Contact the CSHCN Program to begin the appeal process.

Failure to submit an appeal, administrative review, or due process hearing request in writing to the program within the deadlines defined below is considered a waiver of the right to appeal, to administrative review, or to due process hearing.

Denied claims must be resubmitted for appeal within 180 days from the date of the initial denial. Claims denied on written appeal must be submitted for administrative review within 30 days of the date on the appeal denial letter. A due process hearing must be requested within 20 days of the date on the administrative review denial letter.

Denied authorizations must be submitted for appeal or administrative review within 30 days of the date when authorization of services was denied. All appeal materials, including medical reports, forms, and a medical/financial rationale for appeal must be submitted within the deadline. A due process hearing must be requested within 20 days of the date on the letter denying administrative review.