According to the Centers for Medicare & Medicaid Services' regulations, when an authorization request for admission to a post-acute facility (i.e., Long-Term Acute Care Facility, Skilled Nursing Facility, and Acute Rehabilitation Facility) results in an adverse plan decision and new clinical evidence is available, you must submit it as a member appeal within 60 days of the initial decision. Additional clinical information cannot be presented to the Clinical Services – Utilization Management department for review. An appeal may be submitted within 180 days from the receipt of the adverse decision. Note: This procedure applies to both commercial and Medicare Advantage members.
Appeals for denials can be submitted as outlined below.
Commercial members
New Jersey
- Mail:
Member Medical Necessity Appeals – NJ
AmeriHealth New Jersey Appeals
259 Prospect Plains Rd. – Building M
Cranbury, NJ 08512 - Fax: 609-662-2480
- Call: 1-877-585-5731
Pennsylvania
- Mail:
Member Appeals
P.O. Box 41820
Philadelphia, PA 19101 - Fax: 1-888-671-5274
- Call: 1-888-671-5276
Medicare Advantage members
- Mail:
Medicare Member Appeals & Grievances
P.O. Box 13652
Philadelphia, PA 19101 - Fax: 215-988-2001
- Call the Member Help Team at the number listed on the back of the member?s ID card.
If new evidence becomes available after the 60-day period, a new authorization request should be submitted using the Authorizations transaction on the NaviNet® web portal or by calling 1-888-YOUR-AH1 for New Jersey or 1-800-275-2583 for Pennsylvania and following the prompts for Authorizations.
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