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Medicaid Appeal Process

 

Waiver Services and Requirements are subject to change. To ensure you have current information contact the Richland/Lexington Disabilities and Special Needs Board.

TO DOWNLOAD WORD DOCUMENT CONTAINING THE INFORMATION BELOW: CLICK HERE.

SCDDSN RECONSIDERATION PROCESS

The South Carolina Department of Disabilities and Special Needs (SCDDSN) is responsible for the day-to-day operations of the Intellectual Disability-Related Disabilities (ID-RD) Waiver, the Community Supports (CS) Waiver, the Head and Spinal Cord Injury (HASCI) Waiver, and the Pervasive Developmental Disorder (PDD) Waiver.  If a Waiver participant disagrees with a decision made and/or action taken by SCDDSN, reconsideration and reversal of the adverse decision/action may be requested.  

The SCDDSN reconsideration process must be completed in its entirety before seeking an appeal with the
South Carolina Department of Health and Human Services (SCDHHS), which is the State Medicaid Agency.

A request for a SCDDSN reconsideration of an adverse decision/action must be made in writing within thirty (30) calendar days of receipt of written notification of the adverse decision/action.  The request must clearly state the basis of the complaint, previous efforts to resolve the complaint, and relief sought.  If necessary, a Case Manager or other staff may assist the participant, legal guardian or representative in requesting reconsideration.  The request must be dated and signed by the participant, legal guardian or representative assisting the participant.  The request for reconsideration must be mailed to:

State Director                     
SC Department of Disabilities and Special Needs     
P.O. Box 4706                    
Columbia, SC  29240

The State Director or a designee will issue a written decision within ten (10) working days of receipt of the written reconsideration request and mail it to the participant, legal guardian or representative.  If the State Director upholds the original adverse action/decision, the reason(s) shall be specifically identified in the written notification.

Note:  In order for affected Waiver services to continue during the SCDDSN reconsideration process and the SCDHHS Medicaid appeal process, the participant, legal guardian or representative’s request for SCDDSN reconsideration must be submitted within ten (10) calendar days of receipt of written notification of the adverse decision/action.  Continuation of the affected Waiver services must be specifically requested in the request for SCDDSN reconsideration.  If the adverse decision/action is upheld, the participant or legal guardian may be required to repay the cost of affected Waiver services received during the time of the reconsideration/appeal processes. 

SCDHHS MEDICAID APPEAL PROCESS

If the participant, legal guardian or representative fully completes the SCDDSN reconsideration process above and is dissatisfied with the result, the participant, legal guardian or representative has the right to request an appeal with the State Medicaid Agency, which is the South Carolina Department of Health and Human Services (SCDHHS). 
The appeal request may be made electronically using the SCDHHS website indicated below or it may be mailed to SCDHHS.  This must be done no later than thirty (30) calendar days after receipt of the SCDDSN notification.

The purpose of a SCDHHS administrative appeal is to prove error(s) in fact or law pertaining to a decision made and/or action taken by SCDDSN that adversely affects a Waiver participant.  The appeal must clearly state the specific issue(s) that are disputed and what action is requested.  A copy of the reconsideration notification received from SCDDSN must be uploaded using the SCDHHS website indicated below or included with the mailed appeal.

The, participant, legal guardian or representative is encouraged to file the appeal electronically at www.scdhhs.gov/appeals.
OR                                                                                                                                                                                                         
The appeal request may be mailed to:   
SC Department of Health and Human Services
Division of Appeals and Hearings                 
P.O. Box 8206                                    
Columbia, SC  29202-8206

An appeal request to SCDHHS is valid if filed electronically or mailed to the above address and postmarked no later than the thirtieth (30th) calendar day following receipt of the SCDDSN reconsideration notification.  Unless a valid appeal request is made to SCDHHS, the SCDDSN reconsideration decision will be final and binding.  

If a valid appeal request is made, the participant, legal guardian or representative will be advised by the SCDHHS Division of Appeals and Hearings as to the status of the appeal request, which may include a scheduled hearing.


Richland/Lexington Disabilities and Special Needs Board
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