​​​​​​​​​Appeal​​

Applicants must file a written appeal within 60 calendar days of the action, failure to act, or receipt of notice of decision being appealed.  An appeal must include a copy of the letter regarding a decision being appealed or a written statement of the action or failure to act, a statement from applicants as to what is being disputed and the requested resolution and any other relevant information applicants wish to include.

If an appeal is incomplete or does not concern at least one of the three issues listed above or is received beyond the specific timeframe, (i.e., 60 days), applicants are not entitled to a full appeal and the administrative vendor will review the request and process as a Program Review.

Appeals received will be reviewed within four (4) business days.  Once a determination is made that the dispute from the applicant is an appeal, the administrative vendor shall forward the appeal to DHCS within 5 business days.

Exceptions:  The following will be forwarded to DHCS if:

• The issue includes an outstanding medical bill(s) incurred due to a dispute on the effective date of coverage; or
• The issue is of a sensitive nature and the referral has been approved (i.e., request from legislative member or request pertains to a policy issue currently under review or pending revision); or
• The applicant sends a dispute that does not meet one of the three appealable reasons listed above for the second time.  

DHCS will adjudicate the appeal. Once DHCS makes a determination to enroll, disenroll, or other actions, the administrative vendor will be notified. Upon receipt of the notification, the administrative vendor must process the request within 2 business days and provide confirmation to DHCS that the action is complete.

​