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Appeals and Grievances

Important Information About Your Appeal Rights

There are 2 kinds of appeals:

Standard Appeal – An appeal is the process to review a decision you may not like. If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. You will get a written answer on standard appeal 15 business days after we hear from your appeal. We may take longer if you ask for more time, or if we need to know more about your case. We will tell you if we are taking extra time and will explain why more time is needed. 

If you had to pay for a services and want to be paid back, you can ask us. If your appeal is to pay you back, we will tell you in writing. We will tell you in 60 days.

Fast Appeal – You will get an answer within 24 hours after we get your appeal.  You can ask for a fast appeal if you or your doctor think your health could be in danger.

If your doctor asks for a fast appeal, you will get one.

If you want a fast appeal but your doctor did not ask, we may not approve it. 

If we don’t give you a fast appeal, we’ll give you an answer in 15 business days.

How to ask for an appeal with IlliniCare Health.

Step 1: 
To ask for an appeal you have to tell us. It can be from you, your representative, or your doctor.

Step 2:

Write, mail, fax, deliver your appeal or call us.

For a Standard Appeal:

IlliniCare Health
ATTN: Appeals and Grievances
7700 Forsyth Blvd
St. Louis, MO 63105

Phone: 1-877-941-0482 (TTY: 711)
Fax: 1-844-273-2671

If you ask in writing, your appeal must include your:

  • Name
  • Address
  • Member number
  • Reasons for the appeal
  • Medical records, notes or a letter from your doctor.
  • Other information that shows why you need the item or service. Call your doctor if you need this information.

You can ask to see these pieces before we decide. It will not cost anything to you.

If you ask for a standard appeal by phone, we will send you a letter telling you what you told us.

For a Fast Appeal:

Phone: 1-877-941-0482 (TTY: 711)
Fax: 1-844-273-2671

What happens next?

If we do not agree with your appeal, we will send you a letter. We will also send your case to an independent reviewer. An independent reviewer is a third reviewer.

If the third party does not approve your request you will receive a letter.  The letter will explain if you have more appeal rights.

You may also have the right to request a State Fair Hearing:

If you do not agree with the final choice made you can request a State Fair Hearing.

Step 1: To ask for a State Fair Hearing you have to tell us. It can be from you, your representative, or your doctor. You must ask us within 30 days from the date we told you it wasn’t covered.

If you ask in writing, your appeal must include your:

  • Name
  • Address
  • Member number
  • Reasons for the appeal
  • Medical records, notes or a letter from your doctor.
  • Other information that shows why you need the item or service. Call your doctor if you need this information.

If you want to ask for a State Fair Hearing related to a standard Illinois Medicaid item or service, the Aging Waiver (Community Care Program, or CCP), or the Supportive Living Facilities Waiver, you may call or write us.

Step 2: Send your request to:

Illinois Healthcare and Family Services

Bureau of Administrative Hearings
Fair Hearings Section
69 West Washington, 4th Floor Chicago, Illinois 60602

Phone: 855-418-4421 (toll free)
TTY 800-526-5812
Fax: 312-793-2005

If you want to ask for a State Fair Hearing appeal related to the Persons with Disabilities Waiver, Traumatic Brain Injury Waiver, or the HIV/Aids Waiver (Home Services Program, or HSP), submit your appeal in writing or over the phone to:

Department of Human Services
Bureau of Hearings
69 West Washington, 4th Floor
Chicago, Illinois 60602

Phone: 800-435-0774
TTY: 877-734-7429
Fax: 312-793-8573

If you have questions, or to get an aggregate number of grievances, appeals and exceptions, please call IlliniCare Health's Member Services at 1-877-941-0482. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free.  

What is a grievance?

A grievance is a complaint about anything other than benefits, coverage, or payment. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You would also file a grievance if you did not think we had responded quickly enough to your request for coverage determination or organization determination, or to your appeal.

Filing a grievance

You or your appointed representative can file a grievance by:

OR

Write, Mail, fax, deliver your appeal or call us.

For a Standard Appeal:

IlliniCare Health
ATTN: Appeals and Grievances
7700 Forsyth Blvd
St. Louis, MO 63105

Phone: 1-877-941-0482 (TTY: 711)
Fax: 1-844-273-2671

If you have questions, please call IlliniCare Health Member Services at 1-877-941-0482. Hours are 8 a.m. to 8 p.m., seven days a week. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free.

 

Last Updated: 02/08/2018
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