Medicaid Appeals

Alliance has the authority to make decisions about Medicaid services because we have a contract with the North Carolina Medicaid agency pursuant to 42 C.F.R. Part 438. We can only approve services that are medically necessary. We base our decision to approve or deny a request for Medicaid services on 10A NCAC 25A .0201, the North Carolina State Plan for Medical Assistance, Medicaid Clinical Coverage Policies, the North Carolina MH/I-DD/SA Health Plan Waiver and the NC Innovations Waiver, and established Clinical Practice Guidelines. If you don’t have internet access or want us to send you a copy of these documents you can call (800) 510-9132.

Attorneys or others wishing to assist an individual in the appeals process must submit this Consent to Release Personal and Medical Information signed by the individual or guardian before Alliance can share Protected Health Information.

Appealing a Denial for Medicaid Services

Alliance will notify you in writing within one business day of any denial of Medicaid-funded service by sending you a Notice of Action letter. This letter tells you why the service request was denied and it contains the Reconsideration Review Request form. This form can be used to ask Alliance to reconsider a decision to deny a service request. The questions and answers below will provide additional information and instruction about the appeals process.

Frequently Asked Questions

What is the first step?

If Alliance does not approve your service authorization request as it was requested, you have the right to appeal. The first step in appealing Alliance’s denial of a request for Medicaid services is to ask for a Reconsideration Review. A Reconsideration Review means that someone at Alliance who was not involved in your case will take a second look at our decision to not approve your Medicaid service authorization as requested. You must request a Reconsideration Review and wait to receive Alliance’s decision before you can ask for “State Fair Hearing.”

How much time do I have to ask for a Reconsideration Review?

Within one business day of the decision to not approve your service request, Alliance will send you a letter notifying you of this denial. This letter will have a form called the Reconsideration Review Request form that you can use to request a Reconsideration Review. A request for a Reconsideration Review must be filed with Alliance within thirty (30) days of the mailing date on this notice. Please call Alliance at (919) 651-8545 if you need assistance filing the request for Reconsideration. Reconsideration requests received after this time will not be accepted or reviewed. Alliance will mail you a letter confirming that we received your request for a Reconsideration Review. This letter is mailed by Alliance within one business day of the date your request was received.

How do I ask for a Reconsideration Review?

To request a Reconsideration Review, complete the request form and fax, mail or hand deliver the form to:

Alliance Behavioral Healthcare
Attn: Appeals Department
4600 Emperor Boulevard, Suite 200
Phone: (919) 651-8545
Fax: (919) 651-8682

You may also call (919) 651-8545 if you want to make your request for Reconsideration by phone, but you will still have to file a signed Reconsideration Review Request Form. Your oral request for a Reconsideration Review will not be processed if we do not receive the signed form within thirty (30) days from the mailing date of this notification. Alliance will help you file the form if you ask us for assistance. For example, if you need help filling out the form, understanding your notice, or accessing interpretation services please contact us at (919) 651-8545 and someone will assist you.

Your provider can file the request for a Reconsideration Review on your behalf if you give them written permission. There is space to give written permission on the Reconsideration Review Request form.

What is the timeline for the Reconsideration Review?

The Reconsideration Review must be completed within thirty (30) days after you file your request. We will schedule this review with a licensed clinician who has the appropriate clinical expertise and had no prior involvement in the initial decision. This person will review the information used in making our decision, in addition to any other information that you wish to submit. If you want the reviewer to consider additional information, please send it to us at the address listed above when you file your Request for Reconsideration Review Form or within ten (10) days of filing this form so that we have enough time to consider the information. We will mail you a decision within 30 days of the date you submitted your Reconsideration Review request.

In some cases more than thirty (30) days to complete the Reconsideration Review may be needed by either you or Alliance. You can ask for an extension if you need more time to get additional information to the clinician completing the Reconsideration Review. Call (919) 651-8545 to arrange for this extension. Alliance may also need additional time to complete the Reconsideration Review. Alliance will only extend the Reconsideration Review timeframe if it is in your best interest. You will be notified promptly in writing if an extension will occur, the reason for the extension, and what you can do if you disagree with the reason for the extension.

What if I want my Reconsideration Review to be processed faster?

You can ask for an expedited Reconsideration Review if you think that waiting 30 days might seriously jeopardize your life, health, or functional abilities. Call (919) 651-8545 to request an expedited Reconsideration review. Your provider can also request an expedited Reconsideration Review on your behalf if you give them written permission.

Alliance will call you within seventy-two (72) hours of your request for an expedited review to let you know if this request was accepted as expedited. If the request is accepted as expedited, your appeal will be processed within seventy-two (72) hours and Alliance will call to tell you the outcome of that review within those seventy-two (72) hours. We will also send you a letter no later than three (3) days after this phone call.

In some cases more than 72 hours may be needed by you or Alliance to complete the expedited review. You can ask for an extension if you need more time to get additional information to the clinician completing the Reconsideration Review. Call (919) 651-8545 to arrange for this extension. Alliance may also need additional time to complete the Reconsideration Review. Alliance will only extend the Reconsideration Review timeframe if it is in your best interest. You will be notified promptly in writing if an extension will occur, the reason for the extension and what you can do if you disagree with the reason for the extension.

We will try to notify you by telephone is your Reconsideration Review request is not accepted as expedited, and a letter to that effect will be mailed within two (2) days of this phone call. Your appeal will be processed within the standard time frame of thirty (30) days. You do not need to submit an additional Reconsideration Review Request form. You can contact (800) 510-9132 to file a grievance about our decision to deny an expedited Reconsideration Review.

How and when do I submit additional information to be considered by the Reviewer?

Additional information should be attached to your request for a Reconsideration Review or it should be received by Alliance within ten (10) days after you asked for the Reconsideration Review.  It can be faxed, mailed or hand delivered to the contacts listed above. If you need assistance submitting additional information, please call (919) 651-8545. Alliance makes every effort to ensure that additional information is considered during the Reconsideration Review so it is important that you submit this information as soon as possible.

You can also request to see the documentation that will be used in the Reconsideration Review. Call (919) 651-8545 to arrange to review this documentation.

Will my services be authorized during the appeal process?

If we terminate, suspend or reduce your current Medicaid services before the authorization period ends, you may continue to receive those services if you meet all of the following conditions:

  • You file a Reconsideration Review request within ten (10) days of the date of the Notice of Clinical Denial and
  • The decision involves the termination, suspension, or reduction of currently authorized services and
  • The services were ordered by an authorized provider and
  • The authorization period for the services has not expired and
  • You request that your services continue.

If all of these conditions are met, you will continue to receive your current services until:

  • You withdraw your request for a Reconsideration Review or
  • Ten (10) days after we mail the Reconsideration Review decision to you, unless you request a State Fair Hearing within those ten (10) days or
  • You lose your State Fair Hearing or
  • The authorization period for the services expires or authorization service limits are met.

If your services are not approved through the Reconsideration Review Process we are allowed to recover from you or your spouse (or your parent or legal guardian if you are under 18) the cost of the Medicaid services you received during the Reconsideration process. We cannot recover these costs from the parents or guardians of individuals over 18 or from providers.

For more details about continuation of benefits, see 42 C.F.R. § 438.420.

What if I disagree with the Reconsideration Review decision?

If  you  disagree with the Reconsideration Review decision you may request a State fair hearing with the North Carolina Office of Administrative Hearings (OAH).

The State Fair Hearing Request form and information explaining how to request a State fair hearing with OAH will be included with the Notice of Resolution letter you receive from Alliance if any part of the original denial was upheld. You must wait to receive this Notice of Resolution before requesting a State fair hearing. Your State fair hearing request must be submitted within thirty (30) days after the mailing date of your Notice of Resolution.

You can also learn more about requesting a State Fair Hearing or by calling (919) 431-3000.

What if I need legal assistance?

To locate a lawyer, please call (800) 662-7660 for the North Carolina Health Information Project Lawyer Referral Service or (800) 662-7407 for the North Carolina State Bar Lawyer Referral Service. You can also call Disability Rights of North Carolina toll-free at (877) 235-4210 or Legal Aid of North Carolina at (866) 219-5262.

Non-Medicaid Appeals

Per 10A NCAC 27G .7004 you may file an The joint federal and state program to assist states in furnishing medical assistance (health insurance) to financially eligible individuals. Federal law concerning the Medicaid program is located in Title XIX of the Act. NC Innovations services are provided under the Medicaid program. All NC Innovations participants have Medicaid coverage.”>Medicaid) service. The first step in that process is to request a days of this notice (10A NCAC  27G.7004). If the deadline falls on a weekend or holiday, then it is due the next business day. This due date is noted on the Reconsideration Review Request form.

  • You can call the Alliance Behavioral Healthcare’s Appeal Department at (919) 651-8547 to request a Reconsideration Review but you will still have to submit a signed form within fifteen working days of the date the Notice of Decision letter was mailed.
  • Your provider or someone else can help you with the Reconsideration Review Request form and process if you give them written permission on the form.
  • You can ask for your Reconsideration Review to be decided sooner if you think that waiting 30 days might seriously jeopardize your life, health or functional abilities. Alliance will contact you within 72 hours of receiving your request for an expedited Reconsideration Review to inform you of when the review will be completed.
  • Someone from Alliance Behavioral Healthcare will respond to you within three days of receipt of your Reconsideration Review Request. You may have someone with you at any meeting that is held to discuss the appeal. This includes, but is not limited to, advocates, personal supporters or a  legally-responsible person. For further information on the appeal process or to seek assistance in completing the appeal contact the Alliance Behavioral Healthcare Appeals Department at (919) 651-8547.

    Note that appeals for the denial for county-funded inpatient services at Holly Hill Hospital follow the process outlined within the contract between Holly Hill Hospital and Alliance and can be explained to you by contacting Alliance’s Appeals Department at (919) 651-8547.

    Attorneys or others wishing to assist an individual in the appeals process must submit this Consent to Release Personal and Medical Information signed by the individual or guardian before Alliance can share


    Page last modified: July 10, 2017