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Grievances and Appeals

What to do if you have an appeal or a grievance

How Member Services can help you.

Call and talk to a Member Advocate whenever you have a problem of any kind with HPN Medicaid or any of our doctors, providers or services. The phone number is 1-800-962-8074, TTY 711. Our Member Services team is here to help you. We can help you with the appeal and grievance process which includes completing any necessary forms. This help includes different ways for you to understand information such as interpreters and aids if you are deaf or blind. You have the right as a Health Plan of Nevada (HPN) Medicaid member to file an appeal or grievance.

Grievances

You have the right to file a grievance if you have an issue with:

  • Services you received through HPN Medicaid
  • The care or services you received from one of our doctors or other health care providers
  • You disagree with our decision to extend the time frame for up to 14 days to resolve your appeal
  • You may file a grievance in two ways:
    • Call us at 1-800-962-8074, TTY 711, or
    • Write to:
      Health Plan of Nevada Medicaid
      P.O. Box 14865
      Las Vegas, NV 89114

We take your grievance seriously and will try to settle it to your satisfaction. If you need help filing a grievance, just call our Member Services Department at 1-800-962-8074, TTY 711. Our representatives will be happy to help you. You must give written permission for someone to file a grievance for you, even your doctor. Oral interpreter services are also available. Once we receive your grievance, the following will occur:

  • We will send you a letter within five calendar days. It will tell you that we have received your grievance. Our staff may also contact you to make sure they understand the situation.
  • Within 45 days of the day we receive your grievance, we will send you a letter letting you know the outcome. We may extend this time by up to 14 calendar days if additional information is needed and the extension will benefit you.

Appeals

You have the right to file an appeal within 60 days of receiving a notice for any of the following issues:

  • The covered services you requested were denied or limited
  • The covered services you were receiving are reduced, suspended or stopped
  • Part or all of the payment for a service you received is denied
  • Your request for covered services was not responded to timely
  • HPN Medicaid does not resolve your grievance or appeal timely

There are two kinds of appeals you can file.

Standard (30 days): You can ask for a standard appeal. We will send you a letter letting you know we received your appeal within five calendar days. We must give you a written decision no later than 30 days after we get your appeal. We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you. If you disagree with the extended time frame, you may file a grievance with HPN Medicaid.

Expedited (72-hour review): You may ask for an expedited appeal if your doctor believes that your health could be seriously harmed by waiting too long for a decision and is willing to support this.

We must decide on an expedited appeal no later than 72 hours after we get your appeal. We may extend this time by up to 14 days if you request an extension, or if we request an extension from the State to obtain additional information and the extension benefits you.

If you disagree with the extended time frame, you may file a grievance with HPN Medicaid. We will call you whenever possible to let you know the decision. If we are unable to contact you, we will send you a written notice of our decision within two days of making the decision. If you would like your provider to ask for an appeal on your behalf, HPN Medicaid must receive written consent from you.

If we decide your request for an expedited appeal does not meet the criteria, we will change it to a standard appeal. We will let you know verbally, whenever possible, and send you written notice within two calendar days. If any doctor asks for an expedited appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we may give you an expedited appeal. Your doctor will need to provide medical records or a letter to support this request.

Who may file an appeal?

  • You, the adult member
  • The parent or guardian of a minor member
  • A person named by you as your authorized representative
  • A provider acting for you as your authorized representative

You must give written permission for someone to file an appeal for you. They would be your authorized representative.

What do I include with my appeal?

You can call Member Services to file an appeal, or write to Member Services with your name, address, member ID number, reasons for the appeal, and any evidence you wish to attach. You may send in supporting medical records, doctors’ letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send this information or present this information in person if you wish or you may authorize another adult to do so on your behalf. We will consider any additional information submitted so long as it is provided before a decision is made on your appeal.

How to file a standard appeal

You or your authorized representative can call to file an oral appeal, mail or hand-deliver your written appeal to the following:

  • Mailing Address:
    Health Plan of Nevada Medicaid
    P.O. Box 14865
    Las Vegas, NV 89114-4865
  • Offices are located at:
    2720 N Tenaya Way, Ste 120
    Las Vegas, NV 89128

In person services are available Monday – Friday from 10 a.m. to 3 p.m. by appointment only.

Standard appeals may be filed by calling our Member Services Department at 1-800-962-8074, TTY 711, 8 a.m. to 6 p.m., Monday through Friday.

How to file an expedited appeal

You or your doctor acting on your behalf, or your authorized representative should contact us by telephone or fax:

  • Fax #: 702-266-8813
  • TTY/TTD: 1-800-349-3538
  • Toll-Free: 1-800-962-8074, TTY 711

If your doctor is acting on your behalf, your written consent must be sent to HPN Medicaid.

Authorized Rep Form

Appeal Form

State Fair Hearing

If you still do not agree with our decision, after all of HPN Medicaid’s appeals have been completed, you or your authorized representative can ask for a State Fair Hearing by contacting the Nevada Medicaid Hearings Unit at 1-775-684-3604 or mailing your request to 9850 Double R Blvd., Suite 200, Reno, NV 89521. You must ask for this hearing within 90 days of receiving the final Appeal Notice from HPN Medicaid. You must give written permission for someone to request a State Fair Hearing for you. You may also request a State Fair Hearing if we fail to make our decision in a timely manner that is within the time frames described in this section.

Expedited Fair Hearing

An expedited State Fair Hearing can be requested if the time allowed for a standard State Fair Hearing may put a person’s life, health or ability to function at risk. The request must be submitted with all the medical information that shows why a faster process is needed. A request for the rushed Fair Hearing can be made online, by telephone, in person or in writing.

Continuation of service during the appeal or State Fair Hearing (SFH) process

If you would like to appeal a Notice of Action or Adverse Determination you have received from HPN Medicaid, you can request to have covered services you are receiving continued during the appeal or SFH process.

You will need to make the request for continuation of covered services within ten (10) calendar days of the date of the Notice of Action if your Appeal or SFH involves the following:

  • The termination of covered services,
  • The suspension of covered services, or
  • The reduction of covered services.

Your request for continuation of covered services can be made so long as the continued covered services are ordered by an authorized provider. Your request will be considered if the original periods covered by the original authorization have not expired or your request has not exceeded the intended effective date of HPN Medicaid’s proposed action.

If your covered benefits are continued by HPN Medicaid pending the outcome of an Appeal or SFH, they will be continued until one of the following occurs:

  • You withdraw your Appeal or SFH;
  • Ten (10) calendar days pass after the notice of action is mailed (unless the enrollee requests an Appeal or SFH and continuation of benefits until the hearing decision is reached);
  • The plan or hearing officer issues an adverse decision to the enrollee; or
  • The time period governing service limits of a previously authorized service have been met.

If you do not win your appeal or SHF, you may be required to pay for the services that you received during the Appeal and State Fair Hearing process.

Additional Resources

If you need information or help, call the State Medicaid Office at:

  • Las Vegas: 702-668-4200 or 1-800-992-0900
  • All other areas: 1-866-569-1746

If you need legal assistance, call the Legal Services Program:

  • Clark County: 702-386-0404 or 1-866-432-0404
  • https://nevadalegalservices.org/contact/

If you need information or help, call HPN Medicaid at:

  • Toll-Free: 1-800-962-8074, TTY 711
  • TTY/TTD: 1-800-349-3538

We can help you through the grievance and appeals process. Interpreter services are available. We can help you or your representative get a ride to the hearing. We are available from 8 a.m. to 6 p.m., Monday through Friday. You have a right to review your case file, including medical records and any other documents and records used during the appeals process.