• decreaseincrease
  • pdf
Last Updated: 5/10/2023

Appeal Process

An appeal is defined as a participant’s and/or caregiver’s action with respect to Pace of the Ozarks non-coverage of, reduction of or non-payment of a service. An appeal may be expressed either orally or in writing to any staff member at any time. A staff member may assist you in filling an appeal; and you will be given reasonable opportunity to present evidence related to the dispute related to the dispute in person or in writing.

The appeal process will be reviewed with you and your caregiver at the time of enrollment, at least annually thereafter and if at any time the Interdisciplinary Team denies any request for service or payment. If a request for a service or payment of a service is denied, information on how to file an appeal will be provided. A team member will also discuss with you the appeal process.

You may file an appeal if Pace of the Ozarks:

  1. Denies a Service: refuses to provide a service you have requested
  2. Reduces a Service: reduces a previously approved service you are presently receiving
  3. Denies Payment for a Service: refuses to pay for a service you have already received
  4. Does Not Act Promptly: fails to respond in the required time to a request for services or payment
  5. Disenroll you on an involuntary basis
  6. Refuses to enroll you in the program

Denial of Services

When you make a request for a service to your care team, we must give you an answer within 3 days. This time frame can be extended up to an additional 5 days if it is in your best interests to do so.

If your care team denies your request for a service, or fails to respond in the required time, you may submit an appeal to Pace of the Ozarks. You must request a standard appeal or an expedited appeal within 30 days of the day the plan notifies you that your request has been denied. You may submit your appeal by yourself or with the help of someone of your choosing.

Reduction of Services

If your care team plans to reduce the amount or frequency of a service, you are presently receiving we must provide you with written notice at least 10 days in advance. Please note that we are not required to notify you if your physician orders the reduction.

You may only appeal a reduction in a previously authorized service. It is not a reduction in service if you have received all the services that were originally authorized. In such cases, participants who wish to receive additional services must submit a new request for these services. This request will be subject to the rules described earlier for any request for service.

If your care team notifies you that it still plans to reduce a service as described, you may submit an appeal to Pace of the Ozarks.

When an Appeal is Filed

If an appeal is filed, Pace of the Ozarks will continue to furnish the disputed services to you until issuance of the final determination of the appeal. However, please be aware you may be liable for the cost of the services in the event the appeal is not made in your favor. You will not be discriminated against because an appeal has been filed. Confidentiality will be maintained throughout the process and information pertaining to your appeal will only be released to authorized individuals

There are two types of appeals you may file:

Standard (30 days) – You may ask for a standard appeal. We must give you a written decision no later than 30 calendar days after we get your appeal

Expedited (72-hour review) – You may get an expedited appeal if you or your doctor believes that your health could be seriously harmed by waiting too long for a decision. We must decide on an expedited appeal no later than 72 hours after we receive your appeal request. We may extend this time by up to 14 days if you request an extension or if we demonstrate to the state the need for additional information and the need for the extension and how it would benefit you.

When you file an appeal, an appropriately credentialed and impartial third party will complete a review of the appeal and provide a decision to uphold or overturn the previous decision. You may request to speak with and present your reason for the appeal. You may designate a representative to speak and present your appeal.

If the decision made on your appeal is not in your favor, you have additional appeal rights. Your request to file an external appeal can be made either verbally or in writing. The next level of appeal involves a new and impartial review of your appeal through either the Medicare or Medicaid program.

If you receive Medicare, you may submit a written request for reconsideration must be filed with the independent review entity within 60 calendar days from the date of the decision by the third party reviewer under using Medicare’s external appeals process. The Medicare program contracts with an Independent Review Entity (IRE) to provide an external review on appeals. Pace of the Ozarks will submit your appeal for impartial review. After review, the IRE will contact Pace of the Ozarks with the results of the review. The IRE will either maintain the original decision (uphold) or change (over turn) the original decision.

If you need information of help, call us at: 479-463-6600

1-800-MEDICARE (1-800-633-4227) TTY/TTD: 1-877-486-2048

If you are a Medicaid recipient or Medicaid only recipient, you may file an appeal through Medicaid. The Medicaid program conducts their next level of appeal review through the State’s Fair Hearing Process:

Arkansas Department of Human Services
Office of Appeals and Hearings
P.O. Box 1437 - Slot N401
Little Rock, AR 72203-1437