Appeals

An appeal is a request for a review of our action to deny or limit authorization or payment for health care services including:

  • New authorizations
  • Previously authorized services
  • A reduction, suspension, or termination of a previously authorized service
  • Our failure to provide services in a timely manner
  • Our failure to resolve grievances or appeals within the timeframe specified
  • Our denial of a request by an enrollee who resides in a rural area with only one network provider to receive out-of-network services

What should I do if I have an appeal? 

You may choose to appeal the decision if you have received a “Notice of Action” and you are unhappy with the decision.  With your written permission, your doctor or someone else you choose may file on your behalf.  To file an appeal, you or your representative should put the appeal in writing and send it to:

West Virginia Family Health
PO Box 22278
Pittsburgh, PA  15222

You may call Member Services for help in filing your appeal.  We will then put your appeal in writing and send it to you for your signature.  You will need to return your appeal with a signature before your appeal can be processed.  Your appeal will be processed without a signature for a request of a quick decision.  There is no cost to you to file an appeal.

When should I file an appeal? 

You must file your appeal within 60 days from the date of the “Notice of Action” letter.  Your representative may file on your behalf if you give your ok in writing to do so.                  

What happens after I file an appeal? 

You will get a letter from us within 5 working days after your appeal.  This letter will tell you that we have received your appeal.  It will also include information about the appeal review process.  You may choose someone to act on your behalf.  You or your representative may submit additional information.  You or your representative may look over all documents regarding the appeal upon request free of charge. 

One of our staff members, who has not been involved but knows the most about your issue, will review your appeal.  A decision will be made within 30 days after we receive your appeal. 

You or your representative may extend the timeframe for decision of the appeal up to 14 days.  We may also extend the timeframe for decision of the appeal up to 14 days if additional information is necessary and the delay is in your interest.  If we extend the timeframe, we will send you a written notice of the reason for the delay.

A decision letter will be mailed to you after the decision is made.  This letter will tell you the reason(s) for the decision and further appeal rights.  If you have a problem with our decision, the Bureau for Medical Services (BMS) and the Office of the Insurance Commissioner can help you.  Depending on the type of problem you have, you can ask for a State fair hearing or file an appeal with the WVOIC. If the appeal does not qualify for a State Fair Hearing (see “What should I do to get a State Fair Hearing” below), you should send your appeal to:

West Virginia Offices of the Insurance Commissioner
Member Appeals Department
PO Box 50540
Charleston, WV   25305-0540

All notices can be provided in a language other than English or in another format (i.e. Braille) for those who are unable to see or read written materials. We have oral interpretation services available in non-English languages free of charge. If you need these services, please call Member Services.

What should I do if I need a decision faster than 30 days? 

If you received a Notice of Action and the decision to deny services could seriously jeopardize your health and well-being, you or your representative may ask for an expedited appeal.

An expedited appeal may be requested orally or in writing by you, your representative, or by your provider (with your written consent).  If we agree that your appeal should be expedited, you will receive a decision within 72 hours.  If we do not agree, your appeal will follow the standard appeal process.  You or your representative may extend the timeframe for decision of the expedited appeal up to 14 days.  We may also extend the timeframe for decision of the expedited appeal up to 14 days if additional information is necessary and the delay is in your interest.  If we extend the timeframe, we will send you a written notice of the reason for the delay.

What to do to continue getting services during the appeal process? 

If you have been receiving services or items that are being reduced, changed or stopped, and you file an appeal that is submitted within 10 days of the date on the Notice of Action letter or the effective date of the proposed action, your benefits may continue until a decision is made.  You may have to pay for these services while your appeal is pending if the final decision is not in your favor.

What if I don’t like WVFH’s decision about my appeal? 

If you do not agree with our decision, you, or your representative, may ask for a State Fair Hearing. You may also file an appeal with the WVOIC when appropriate.

State Fair Hearing

A State Fair Hearing is an appeal process provided by the State of West Virginia.  You must go through our appeal process before requesting a State Fair Hearing.  You must participate in a State Fair Hearing.  We will also have a representative at a State Fair Hearing.

What should I do to get a State Fair Hearing? 

You, or someone you choose, may ask for a State Fair Hearing if:

  • We have denied, terminated, or reduced a service.
  • We have failed to give you timely service.

You can request a State Fair Hearing by completed the attached “Request for Hearing" form and sending it to the following address:

Bureau for Medical Services
Appeals Sections
Room 251, 350 Capital Street
Charleston, West Virginia 25301-3706

If you need help completing the form please contact WVFH Member Services at 1-855-412-8001.

When should I file a State Fair Hearing? 

If you, or someone you choose, are not happy with the appeal decision, you may request a State Fair Hearing within 120 days of the date on the appeal decision letter.

What happens after I file a State Fair Hearing?  You or someone you choose will receive a letter from the hearing officer that will tell you the date and time of the hearing.  The hearing can be held by telephone.  The letter will also tell you what you need to know to get ready for the hearing.  You or your representative may review all documentation regarding the State Fair Hearing.

The DHHR will give you a final decision in writing within 90 days from the date you asked for the hearing.  

What to do to continue getting services during the State Fair Hearing process? 

If you have been receiving services or items that are being reduced, changed or stopped, and you file a State Fair Hearing that is submitted within 10 days of the date on the appeal decision letter, your benefits may continue until a decision is made.  You may have to pay for these services while your State Fair Hearing is pending if the final decision is not in your favor.

What if I do not like the State Fair Hearing decision? 

If you, or someone you choose, are unhappy with the State Fair Hearing decision, you or your representative can take your case to the Circuit Court.  You must file with the Circuit Court within 120 days of the date of your notice of the State Fair Hearing decision.

Appeals after 60 calendar days

If you did not ask for a State Fair Hearing within the timeframe, you may still be able to appeal the original ruling.  You can use this process for any type of appeal.

To file this appeal, you must complete our internal process first.  Your filing must be within one year from the date of the first ruling that you did not agree with.

Send your request for an appeal to the Bureau for Medical Services (BMS) at the address below:

Bureau for Medical Services
Office of Medicaid Managed Care
350 Capitol Street, Room 251
Charleston, WV 25301-3709

BMS only will review appeals that have to do with a service that was denied, reduced or has ended, but was approved before or if you were not given timely service.  BMS will send you its answer in writing.

If you have a problem with what BMS decides, you can appeal to the Insurance Commissioner by sending your appeal to:

The Office of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540

If you do not agree with what the Insurance Commissioner decides, you may appeal to the Circuit Court.  You must file your appeal within 30 calendar days after the Insurance Commissioner’s order was mailed.