Grievances, Appeals, and Independent External Reviews

Grievances

If you are unhappy with something that happened to you, you can file a grievance. 

  • Examples of why you might file a grievance include:
    • You feel you were not treated with respect
    • You are not satisfied with the health care you received
    • It took too long to get an appointment
  • To file a grievance, you should call Enrollee Services at 1-844-214-2470 (TTY 711)
  • You can file a grievance in writing to:
    AmeriHealth Caritas District of Columbia
    Healthy DC Plan
    Enrollee Services Grievances Department
    200 Stevens Drive, Philadelphia, PA 19113
  • Your authorized representative or provider can also file a grievance for you
  • You should file a grievance as soon as possible after the event that caused you to be unhappy. Please include any information you believe supports your case.
  • Once we have received your grievance, we will send you written acknowledgement of receipt within two business days of receiving it. After we research your concern, we will send you a written notice on how your concern has been resolved. In most instances, we will provide you with this written notice within 90 calendar days of receiving your grievance. On rare occasions, we may ask for an additional 14 calendar days for resolution, especially if more information is needed that would be helpful to resolving your grievance. 
  • At any time, you can request free copies of all records and other information we have relevant to your written grievance by calling Enrollee Services at 1-844-214-2470 (TTY 711).

Appeals

If you believe your benefits were unfairly denied, reduced, delayed, or stopped, you have a right to file an appeal with AmeriHealth Caritas District of Columbia (DC).

  • To file an appeal with AmeriHealth Caritas District of Columbia, call Enrollee Services at 1-844-214-2470 (TTY 711) 
  • You can file in writing by faxing to 1-844-214-2475 or mailing to:
    AmeriHealth Caritas District of Columbia
    Healthy DC Plan
    Attention: Appeals Coordinator
    Enrollee Appeals Department
    200 Stevens Drive
    Philadelphia, PA 19113-1570
  • An appeal must be filed within 180 days from the date of our written notice denying your claim or your request for service. The appeal procedure is voluntary on the part of the enrollee and may be initiated by you or an authorized representative, including your provider. You may submit evidence or testimony to support your appeal.
  • Once we have made a decision on your appeal, we will send you written notice of the decision no later than 30 calendar days for pre-service requests and 60 calendar days for post-service requests after receiving your appeal. A standard non-formulary pharmacy appeal is resolved within 72 hours.

Expedited appeals

An expedited appeal can be requested by you, your authorized representative, or your provider either verbally or in writing. You, your representative, or provider can file a request for an expedited appeal with our Enrollee Services department by phone at 1-844-214-2470 (TTY 711). You can file in writing by faxing to 1-844-214-2475 or mailing to:

AmeriHealth Caritas District of Columbia
Healthy DC Plan — Expedited Appeals
Attention: Appeals Coordinator
Enrollee Appeals Department
200 Stevens Drive
Philadelphia, PA 19113-1570

  • You will have the opportunity to provide evidence in support of your appeal by phone, in writing, or in person.
  • We will give you a written or oral decision on an expedited appeal within 72 hours after we get your appeal. For expedited non-formulary pharmacy appeals, they are resolved within 24 hours. If we decide that your request is not an emergency, we will notify you within 72 hours and your appeal will be moved to the standard appeal process. If you disagree, you have the right to file a grievance. 

For both standard and emergency appeals. If you want more time to submit information to support your appeal, you can ask us to delay our decision up to 14 more calendar days. Also, if we need to gather more information to decide your appeal, we can take up to 14 more calendar days to make our decision. If we need extra time, we will attempt to give prompt verbal notice, and a written notice is sent within two calendar days. 

Independent external review procedure

District of Columbia law makes available to you an independent external review of adverse determination decisions made by AmeriHealth Caritas DC. The external review will be performed by a third-party independent review organization (IRO) who is not associated with AmeriHealth Caritas DC. This service is provided to you at no charge. External review is performed on a standard or expedited timetable, depending on which is requested, and on whether medical circumstances meet the criteria for expedited review.

  • A request for external review may not be made until you have exhausted our internal appeal process.
  •  Your request for standard external review must be submitted in writing to AmeriHealth Caritas DC within four months of receiving our notice of final determination that the services in question are not approved. You or your authorized representative can submit this request by faxing 1-844-214-2475 or writing to:
    AmeriHealth Caritas District of Columbia
    Healthy DC Plan
    Attention: External Review Request
    Enrollee Appeals Department
    200 Stevens Drive
    Philadelphia, PA 19113-1570

     

  • Within five business days of receipt, we will complete a review of your request to determine if you meet the eligibility requirements for external review.
  •  If your request for external review is accepted, we will assign an IRO. The IRO will communicate its determination within 45 calendar days for standard external review requests and within 72 hours for expedited external review requests from the date they received the initial request.
  • The IRO’s external review decision is binding.

If you have any questions or concerns regarding the independent external review process, please contact Enrollee Services at 1-844-214-2470 (TTY 711).

If you are not satisfied with the help provided by Enrollee Services, you may contact the District of Columbia Office of Health Care Ombudsman and Bill of Rights for help. You may call the Health Care Ombudsman at 202-724-7491 (office) or 1-877-685-6391 (toll-free); TTY users should call 711. You may also email the Health Care Ombudsman at healthcareombudsman@dc.gov.