Provider Appeals

Provider Information

Provider Name *

First Name *

Last Name *

Provider Number

Provider Phone Number

Address

Address 2

Please list all beneficiaries appealing

Do You Have a Representative?

Representative Information

Name

Address

Address 2

Phone Number

FAX

Are you an attorney?

Beneficiary Information

First Name

Last Name

Address

Phone Number

Address 2

Phone Number

Medicaid ID

Household Number

List of Everyone Appealing

Is the beneficiary enrolled in an MCO

Which one

Have you exhausted the appeals process with your MCO?

You must exhaust the internal appeals process with your MCO before you can appeal to the Office of Appeals and Hearings.

Documentation

Please state why or how you think the agency erred or why you are appealing.

Description

If you would like to attach the denial notice, authorized representative form/notice of appearance, or supporting documentation, please do so now. The notice is required at this time, but you will have an opportunity to submit additional documentation after your appeal is received.

Denial Notice

Please save Microsoft Word documents as .PDF
Files must be less than 8 MB.
Allowed file types: jpg jpeg png txt pdf zip.

Additional Records/materials

Please save Microsoft Word documents as .PDF
Files must be less than 8 MB.
Allowed file types: jpg jpeg txt rtf pdf zip.

Accommodations

Do you or your representative require special accommodations?

Select Special Accommodations if Needed

If so, please let us know how we can assist you

Most hearings are held at the SCDHHS main office in downtown Columbia, where metered parking can be limited. Would you like us to reserve parking for you for purposes of the hearing?

Yes/No

The Office of Appeals and Hearings will make every effort to obtain and reserve parking for hearing participants. However, reserved parking is not guaranteed. You will be notified if we are unable to reserve parking for you.

Electronic Communications

You can receive all documents from the Eligibility Appeals Coordinators and Office of Appeals electronically. If you choose to receive communication electronically, the Office of Appeals or Eligibility Appeals Coordinators will send you a written confirmation. We will also send a test message to your email address and ask you to confirm you received it.

Please note: If you elect to receive communication electronically, we will email the message or document to you and it is presumed to have been delivered to you if it does not bounce back to us. If a message bounces back, we will resend it one more time. If the second attempt bounces back, we will place a copy of the correspondence or document in the mail to you.

EC Yes

Yes

I would like to receive all communications and documents from the Office of Appeals and the Eligibility Appeals Coordinators electronically.

EC Assumtion

Yes

I understand that all communication and documents will come to me via the email address I provide and will be presumed delivered if it does not bounce back.

Email Address

Please provide the email address to which all communications and documents should be sent

Are you appealing a prior authorization issue? *

Has the beneficiary received the service? *

Is it part of an ongoing service? *

Are you appealing a claim/payment issue(s)? *

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Provider Appeals

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Provider Appeals

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