Children and Youth with Special Health Care Needs Program Provider Manual
Appeal Process
Special Health Care Needs (SHCN) enrolled providers have the right to appeal decisions regarding denial of payment for services.
To appeal a decision made by SHCN, the provider must submit the following documentation to the Program Manager within thirty (30) calendar days of the SHCN warrant/voucher date:
- A letter describing the reason for the appeal;
- Documentation to support overturning the denial; and
- A copy of the claim being appealed.
The Program Manager will review the documentation and render a written decision to the provider within thirty (30) business days of the receipt of the appeal.
If the decision is unsatisfactory, the provider may submit a second appeal letter addressed to the Bureau Chief. The appeal and supporting documentation must be received by SHCN within thirty (30) calendar days of the Program Manager’s written decision date. The Bureau Chief will review the documentation and render a written decision to the provider within thirty (30) business days of the receipt of the appeal.
If the decision is unsatisfactory, the provider may submit a final appeal letter to the Department Director, or designee. The appeal and supporting documentation must be received by SHCN within thirty (30) calendar days of the Bureau Chief’s written decision date. The Department Director will make a final decision based on the evidence and documentation submitted with the appeal. A letter outlining the Director’s decision will be mailed to the provider within thirty (30) business days of the receipt of the appeal.