Complaints and Appeals

An Appeal is a request to review a service that has been denied, limited, reduced or terminated. Appeals may be filed by a member (parent or guardian of a minor member), a representative named by a member, or a provider acting on behalf of a member. An Appeal gets us to review a denial decision to make sure it was the right decision.

You can appeal a decision that:

• Denies the care requested
• Decreases the amount of care provided
• Ends care that was previously approved
• Denies payment for care you may have to pay for

These types of decisions are called “Adverse Actions.” If any of these actions occur, we will send you a letter explaining what the decision is and why we made that decision. It will also include information about your appeal rights.

You may file an Appeal within 60 calendar days from the date on the Adverse Action letter. You may also request copies of any documentation Louisiana Healthcare Connections used to make the decision about your care or Appeal. You can also request a copy of your member records.

Louisiana Healthcare Connections maintains records of each Appeal, as well as all responses, for six (6) years.

We will not hold it against you or treat you differently in any way if you file an Appeal.