Grievances and Appeals

An appeal is the request to change a previous decision, or Action, made by Absolute Total Care. This review makes us look again at the Action.

 An Action is when Absolute Total Care:

• Denies or limits a requested service
• Reduces, suspends, or terminates a service that has already been approved
• Denies payment for a service
• Fails to provide services in a timely manner, as defined by the state
• Fails to act within the timeframes provided
• Denies a member, who is a resident of a rural area where there is only one MCO, request to exercise his or her right to obtain services outside the Absolute Total Care network

Upon taking an Action, Absolute Total Care will send the member or member’s representative a Notice of Action letter. The Notice of Action letter will explain the appeals process and includes a copy of the Appeal Form. The Appeal Form can also be found on our Member Handbooks and Forms page. An appeal may be filed within 90 calendar days from the receipt of the Notice of Action letter. If the member or the member’s representative need assistance with their appeal, call Absolute Total Care at 1-866-433-604 and Absolute Total Care will assist them in filing their appeal. This includes providing assistance with accessing interpreter services and hearing impaired services, if needed, at no cost to them.

Who can file an appeal?

• An Absolute Total Care member or a member’s authorized representative.
• An authorized representative is a person or a provider who the member gives the right to act on their behalf. 

The member can give permission for a person or a provider to act on their behalf in writing or by completing the Appointment of Authorized Representative Form found on our Member Handbooks and Forms page or by contacting Member Services at 1-866-433-6041.

There are two kinds of appeals:

Standard Appeal – We will provide a written decision within 30 calendar days from the date of receipt of the request.

Expedited Appeal – A member or member’s representative can ask for an expedited (or fast) appeal if the member, member’s representative or their provider believe their health could be seriously harmed by waiting up to 30 calendar days for a decision. We will provide a written decision within 72 hours from the date of receipt of the request. We will also make efforts to contact the member and their provider by phone of our decision.  No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal

Contact our Grievance and Appeals Coordinator at 1-866-433-6041 if an expedited appeal is needed. An expedited appeal does not require written confirmation.

If the request for an expedited appeal is denied we will make efforts to contact the member and provider promptly by phone. In addition, the member and provider will be sent a written notice within 72 hours from date of receipt of the expedited appeal. Absolute Total Care will follow the standard appeal timeframe and provide a written decision within 30 calendar days from the original appeal request.

Absolute Total Care may extend the timeframe to resolve a standard or an expedited appeal up to 14 calendar days if the member or member’s authorized representative request an extension, or Absolute Total Care can demonstrate that there is a need for additional information that is in the member’s best interest. The member will be notified in writing of the reason for the additional time to resolve the issue. 

The appeal will be reviewed by a medical director who was not involved in the prior decision and will make the final decision for your appeal request.  

The member or member’s representative have the right to present evidence and facts in person, in writing or by phone.

A member or member’s representative may file an appeal by:

• Calling Member Services at 1-866-433-6041. For a standard appeal, Absolute Total Care must receive a written request confirming the appeal within 30 calendar days. An expedited appeal does not require written confirmation.
• Mailing, emailing or faxing a completed Appeal Form or a letter about the appeal. An Appeal Form can be found on our Member Handbooks and Forms page. A copy of the Appeal Form is also included with the Notice of Action letter. Be sure to include:
  • Member first and last name
  • Absolute Total Care Member ID card number
  • Member address and telephone number
  • The reason for the appeal

Mail:
Absolute Total Care
Grievance and Appeals Coordinator
1441 Main Street Suite 900
Columbia, SC 29201

Fax: 1-866-918-4457

Email: SC_Appeals_And_Grievs@centene.com

• In person at the address above. For a standard appeal, Absolute Total Care must receive a written request confirming the appeal within 30 calendar days. An expedited appeal does not require written confirmation.

Absolute Total Care will send a letter letting you know that we received the appeal. 

The member or member’s representative have the right to present evidence regarding the appeal in person, in writing or by phone. They also have the right to review any evidence and documents regarding the appeal in person at the Absolute Total Care office address listed above.

Member Rights to State Fair Hearing 

If the member is still not satisfied with the final decision, the member or member’s authorized representative may file an appeal directly to SCDHHS Division of Appeals and Hearings. The request for a State Fair Hearing must be made within 30 calendar days from the date of receipt of the Notice of Resolution letter or Absolute Total Care receives a failure of delivery notification. The member can give permission for a person or a provider to act on their behalf by completing the Appointment of Authorized Representative Form on our Member Handbooks and Forms page.

A request for a hearing must be in writing. Send this request to:

South Carolina Department of Health and Human Services
Division of Appeals and Hearings (Ste. 901)
P.O. Box 8206
Columbia, SC 29202-8206
1-803-898-2600

Who will attend the State Fair Hearing?

A member or member’s representative will attend the State Fair Hearing. A representative from Absolute Total Care will attend.

Continuation of Benefits While an Appeal or State Fair Hearing are Being Decided

The member may ask to keep getting care related to their appeal while we make our decision.  The member, the member’s authorized representative or their provider can request to continue to receive the care within 10 calendar days of the day Absolute Total Care mails the Notice of Action letter or the intended effective date of Absolute Total Care’s proposed Action.

Absolute Total Care must continue the benefits if:

• The member or the Provider files the appeal timely,
• The Action reduces, suspends, or terminates a service that has already been approved,
• The services were ordered by an authorized provider, or
• The original period covered by the original authorization has not expired.

If Absolute Total Care continues or reinstates the care at the member’s request while the appeal is pending, the care must be continued until one of the following occurs:

• The member withdraws the appeal request
• Ten calendar days pass after Absolute Total Care mails the Notice of Action letter providing the resolution of the appeal, unless the member, within the 10-day timeframe, has requested a State Fair Hearing with continuation of benefits until a State Fair Hearing decision is reached
• A State Fair Hearing officer issues a decision adverse to the member
• The time period or service limits of a previously authorized service has been met

If the final resolution of the appeal decision is not in the member’s favor, they may have to pay for the cost of the services furnished while the appeal resolution was pending.

A grievance is an expression of dissatisfaction about any matter other than an Action such as:

• Wait time to see a doctor
• Being treated unfairly by office staff
• Unclean facilities

Grievances may be filed within 30 calendar days of the occurrence. A member or a member’s authorized representative can file a grievance with Absolute Total Care. An authorized representative is a person or provider a member gives the right to act on their behalf.  A member can give permission by completing the Appointment of Authorized Representative Form found on our Member Handbooks and Forms page. 

If needed, Absolute Total Care will assist members in filing a grievance. This includes providing assistance with accessing interpreter services and hearing impaired services, if needed, at no cost to the member. Absolute Total Care cannot and will not treat members differently because they have filed a grievance and their benefits will not be affected.

To file a grievance members can do one of the following:

• Call Member Services at 1-866-433-6041
• Mail, email or fax a completed Grievance Form or written letter telling us why they are not satisfied. Obtain a Grievance Form from our Member Handbooks and Forms page or call Member Services. Information should include:
  • Member’s first and last name
  • Member’s ATC Member ID card number
  • Member’s address and telephone number
  • The reason for the grievance

Mail:
Absolute Total Care
Grievance and Appeals Coordinator
1441 Main Street Suite 900
Columbia, SC 29201

Fax: 1-866-918-4457

Email: SC_Appeals_And_Grievs@centene.com

• Members can present their evidence in person at the address above

Absolute Total Care will send a letter to the member confirming the receipt of the grievance within five calendar days. We will try to make a decision right away. Sometimes we can resolve it on the phone.  If not, we will send a written decision within 90 calendar days from receipt of the grievance. Absolute Total Care may extend the timeframe to resolve the grievance up to 14 calendar days if the member or the member’s authorized representative requests additional time or Absolute Total Care can demonstrate that there is a need for additional information that is in the member’s best interest.  Absolute Total Care will send written notification to the member stating the reason for the additional time to resolve the issue. 

If a member is not satisfied with the first decision of a grievance, the member can request a second review of the grievance within 30 calendar days from the receipt of the notice of the original decision. Absolute Total Care will review the grievance again. The second grievance review will be completed by someone who did not make the decision on the first grievance review. After the first and second review of the grievance have been completed, the member does not have the right to file a State Fair Hearing.