Enrollee Handbook. The Health Plan That Cares.

Transcription

1 322 S. Green Street, Suite 400 Chicago Illinois Enrollee Handbook The Health Plan That Cares.

2 Welcome to CCAI Community Care Alliance of Illinois (CCAI) is a not-for-profit health plan sponsored by safety-net hospitals. CCAI exists to help seniors and adults with disabilities. CCAI provides you with all the same services covered by the State s Primary Care Case Management Program (PCCM) and more, including coordinated care and bonus benefits. Our goal is to help you feel and function better. We do this by creating a care plan that is just for you. We also focus on prevention, health and wellness. Our providers will help you get the right health care at the right time. Note: If you are getting waiver services there is more information available to you in a separate insert. 2 CCAI Contact Information: Enrollee Services: 322 South Green Street Chicago, IL TTY for the Hearing Impaired: Website: Table of Contents CCAI Service Area... 4 Enrollee Service Commitment... 4 Enrollee ID Cards... 4 Your Primary Care Provider and Primary Care Team Selecting a PCP... 5 Anchor Health Homes... 5 Anchor Health Homes Map... 6 Changing Your PCP... 6 Contacting Your Doctors (PCP or WHCP)... 6 Making an Appointment with your PCP... 7 Your Care Team... 7 Care Management and Disease Management... 7 Preventive Services and Health Education... 8 Covered Medical Services... 8 Preventive Services... 9 Health Education... 9 Referral Services... 9 Second Opinion... 9 Emergency Care Urgent Care Emergency Care Hospitalization Behavioral Health Transportation Prescription Drugs Bonus Benefits Enrollee Rights Enrollee Responsibilities Disenrollment Procedure Advance Directives (Living Will) Integrated Care Program Grievances and Appeals

3 CCAI Service Area CCAI serves people living in the Chicago area including: Cook, DuPage, Kane, Kankakee, Lake and Will Counties. CCAI also serves people living in the Rockford area including: Boone, McHenry and Winnebago. Enrollee Service Commitment We have an experienced Enrollee Services Staff. They are disability-competent. This means that they are specially trained to answer your questions and help you get the care you need. Call to speak with a member of our staff. This is a free call. Hours are 8:30 a.m. to 5 p.m. Monday through Friday. We can take calls in any language. Information is also available in different formats. These include large font, TTY and more. Our Staff will: give you a welcome call explain how to get services answer your questions send you a CCAI enrollee ID card Enrollee ID Cards Your Enrollee ID card Every CCAI Enrollee receives an ID card. Always carry it with you. The card has: your name your doctor s information Enrollee Services phone number behavioral health services phone number pharmacy information nurse hotline phone number It also has our web address and other important phone numbers that you can call to get help any time, day or night. 4 help you contact your Long-Term Services and Supports or Nurse Care Coordinator schedule medical transportation Your Primary Care Provider and Care Team When you join CCAI you will be asked to choose a primary care provider (PCP). Your PCP is your main doctor or nurse practitioner. They know about the issues that you face. Your PCP will keep your health records and arrange for all of your medical care. This includes preventive care and referring you to a specialist. Your PCP may be a: Family Practice Doctor who cares for people of all ages Internal Medicine Doctor who focuses on adults Nurse Practitioner who has received training to provide primary care Women s Health Care Provider (WHCP) who focuses on women s health Specialist who knows about special health care needs (only for those who qualify) Selecting a PCP You can choose a PCP on our website. You can also call Enrollee Services at and we can help you find a PCP who is right for you. Anchor Health Homes If you don t have a PCP, you might want to select one at a CCAI Anchor Health Home. (But you can choose any PCP in the CCAI network.) Anchor Health Homes are sites of care that have committed to offering a range of services to CCAI Enrollees. They are fully disability accessible. This allows for total access from the parking lot to the exam room. They also offer a wide range of services on-site. CCAI s Anchor Health Homes include: Chicago Area Rockford Area Mt. Sinai Hospital Schwab Rehabilitation Hospital Swedish Covenant Hospital Aviva Women s Health Mercy Hospital & Medical Center St. Bernard Hospital & Health Center PrimeCare Community Health Crusader Clinic Rockford Health System To learn more about Anchor Health Homes, call Enrollee Services at

4 Anchor Health Homes Maps Rockford Chicago Making an Appointment with your PCP You should make an appointment to see your PCP as soon as possible after you join CCAI. This is even more important if you have never seen them before. Most doctors and nurse practitioners work by appointment. Your WHCP and dentist offer practice visits if you get nervous going to the doctor. If you need an appointment, call the PCP s office at the phone number on your ID card. If you are going to be late for your appointment, call the PCP s office to let them know. They may ask you to set up another appointment time. If you need to cancel your appointment, call your PCP s office. Changing your PCP You may change your PCP or WHCP at any time. To do so, call Enrollee Services or visit our website. The phone number to call is You can go to your new doctor the first day of the next month. Contacting Your Doctors (PCP or WHCP) You can call your doctor 24 hours a day. If your doctor is not available, they will have a doctor on call who will care for you. The telephone number for your doctor is printed on the front of your Enrollee ID Card. Remember to carry your Enrollee ID Card with you at all times. If you have a question about your health, a symptom or your medications, you can also call our free nurse hotline at It is available to you 24 hours, 7 days a week. Your Care Team In addition to a PCP, other members of your care team may also include: Registered Nurse who is fully trained in care management Social Worker who can connect you to social and community services Physical, Occupational or Speech Therapist Physician Specialist Peer Support Counselor who has a similar condition or experience to yours Care Management and Disease Management A Nurse Care Coordinator will coordinate your care. They will help your care team develop your Care Plan. You will have the chance to approve your Care Plan. A Nurse Practitioner may visit you in your home. They can assess your health and well-being. Your Nurse Care Coordinator will work with you to help you reach your health goals. They will: get to know you and help you set and reach goals help you get services and supplies you need coordinate your services offer guidance and support serve as a key resource consult with your care team ensure consistency of services act as an advocate for you 6 7

5 To reach your Nurse Care Coordinator, call Enrollee Services. The number is Your Nurse Care Coordinator will tell you the best way to reach them at night and on weekends. You also can call the Nurse Hotline 24 hours/day 7 days/week. Nurses will answer your health questions. The phone number to call is Preventive Services and Health Education All new Enrollees are asked to complete a Health Risk Survey. This form asks about your needs for services including: Medical Social Functional Psychiatric/Psychological Environmental Financial Your answers will be used to develop your care plan. Your Care Team will meet with you every week, month or year depending on your needs. Covered Medical Services Here s a list of some of the medical services we cover. For a complete listing, look in your Certificate of Coverage. This can also be found on our website Medical visits Emergency care Home health care Hospital inpatient services Physical therapy Optical services Preventive Dental services Speech and language therapy Laboratory and x-ray services Behavioral health Preventive services Health and wellness programs Hospice Prescription drugs Family planning Transportation to all appointments is available if needed. To schedule a ride, call Enrollee Services at Please call more than two business days before your appointment to get a ride. Preventive Services We want to keep you healthy. You may get your shots, medical checkups and care through CCAI. You also will get reminders about preventive services. Below are some preventive services we offer: Free Weight Watchers membership Diabetic care program Mammogram program AfterCare program Free health and wellness classes Health Education Health information can be found on our website Health topics are also discussed in the Enrollee Newsletter. CCAI Anchor Health Homes and hospitals will have special events that you can attend. These include special programs and health education classes. Referral Services When you need care that your PCP can t provide, you may be given a referral. A referral is needed to see a doctor other than your PCP. It is also required for specialty care services. Your Nurse Care Coordinator will help you get a referral. You don t need a referral for: You do need a referral for: Regular tests or screenings Urgent care Emergency services Behavioral health and substance abuse services Second Opinion Specialty care Scheduled surgery MRI and CT Scans Scheduled hospitalization Your doctor may want you to have surgery. Or they may diagnose you with a disease. You may want to talk to another doctor. If you do, you have the right to ask for a second opinion. To arrange for one, call Enrollee Services at

6 Emergency Care Urgent Care Urgent Care means you need health care soon, but it is not an emergency. Call your PCP. Do not wait for your next appointment. The name and number of your PCP are on the front of your Enrollee ID Card. Your PCP will listen to you, evaluate your condition and see you within 24 hours, if needed. Examples of urgent care are: Ear aches Skin infections Minor burns or cuts Emergency Care 10 Blistered sunburn Bad cold or sore throat An emergency is any medical problem that would cause death or long term injury if not treated right away. CCAI covers Emergency Medical care. It does not matter where you are or when you need it. In an emergency you should: Go to the nearest emergency room Call 911 Call an ambulance if there is no 911 service in the area Examples of an Emergency Medical Condition include: Heavy bleeding Extreme pain Chest pain Severe burns Passing out Difficulty breathing Shock Poisoning Convulsions or extreme bodily shaking Broken bones Throwing up blood After receiving emergency care, you should have someone contact CCAI within 24 hours or as soon as reasonably possible. Call Enrollee Services at Hospitalization If you need to go to a hospital, your PCP will tell you where to go. They will send you to a hospital that is in the CCAI network. Your PCP will work with CCAI to get approval for your inpatient care. If you are hospitalized after an emergency, you should have someone contact CCAI within 24 hours or as soon as reasonably possible. Call Enrollee Services at When you are stable, you may be moved to a CCAI network hospital. After an Emergency Medical Condition, you must get all your follow-up care through your PCP. Behavioral Health You can get mental health services and help with drug or alcohol abuse from CCAI. You do not need a referral from your PCP. We work with PsychHealth, Ltd., and have more than 650 professionals who can help you. To speak with someone at PsychHealth, call No one will know that you called. Transportation If you need a ride to the doctor, call Enrollee Services. The number is Please call more than two business days before your appointment to get a ride. Rides are for the Enrollee with the appointment. A family member or caregiver may go too. After the appointment, the driver will stop at a pharmacy so you can get prescriptions filled on the way home. Prescription Drugs CCAI has chosen CVS Caremark to provide your prescription benefits. You can go to any CVS store, but most other local pharmacies are in-network too. You should take your CCAI ID card with you to the pharmacy. This will help you avoid filling out claim forms. For up to a 30-day supply, go to a participating pharmacy. For up to a 90-day supply, mail-order prescriptions can be sent to your home. CCAI has a Preferred Drug List. To find out if your medication is on it, go to our website, or call CVS Caremark Customer Care at To find an in-network pharmacy, call Enrollee Services at or visit our website and click the CVS button on the home page. 11

7 Bonus Benefits CCAI rewards our Enrollees with extra free services and Healthy Perks. Enrollees can earn between $10 and $30 in incentive-card credits each time they get certain health services, screenings or go to special classes. Here s how the Healthy Perks Program works: You will receive an incentive card in the mail the first time you complete one item on the Healthy Perks flyer. The card will already have the reward amount in the account. New rewards will be added to your account each time you earn them. You can use your incentive card at retail stores nationwide, including Dollar General, Family Dollar, Meijer and independent pharmacies that accept MasterCard incentive cards. You can purchase health-related items using your Healthy Perks debit card. A few of these include: Food Over-the-counter medications Vitamins/dietary supplements Oral care Note: Your incentive card cannot be used to purchase alcohol or tobacco products. If you lose your card, we will give you a new one. Notify Enrollee Services immediately. The phone number to call is CCAI s Bonus Benefits and Healthy Perks include: No Co-Pays: Enrollees do not pay co-pays: To go to the doctor To go to the Emergency Room For hospital services For prescriptions Medical AfterCare Incentive Program: Enrollees can get incentive-card credits. They must see their doctor within 15 days after An Emergency Room visit ($10) A hospital stay ($20) Adaptive Tai Chi: Information about Tai Chi is on the website at Enrollees can go to classes for free if told to. Chronic Disease Self-Management Programs: Enrollees who have a long-lasting disease can go to classes. CCAI will pay for these classes. Enrollees will get a $25 incentive-card credit just for going. Diabetic Care Program: Enrollees who have diabetes can get a $30 incentivecard credit. They must be in Care Management. Also, they must complete: A PCP visit Blood test Cholesterol screening Eye exam Urine screening Extra Pharmacy Benefits: Enrollees can order their medicine. It will be sent to them in the mail. They can get up to a 90-day supply this way. The phone number to call is Extra Transportation Benefits: Enrollees can get a free ride to the drug store after going to the doctor. Mammogram Program: Female Enrollees over 40 years old can get a $25 incentive-card credit. They must have their annual breast check. Nurse Line: CCAI s Nurse Line is available 24 hours/day 7 days/week. Nurses will answer your health questions. The number to call is Dental Services: Enrollees can get their teeth cleaned and examined two times each year, and periodic x-rays and fillings. These services should be arranged through the Nurse Care Coordinator. Psych AfterCare Rewards Program: Enrollees who see their doctor after going to the hospital for mental health get Jewel-Osco coupons. Enrollees can get a: $20 coupon if they see their doctor within 7 days $10 coupon if they see their doctor within 30 days Vision: Enrollees should have an annual eye exam. Enrollees also have a benefit of up to $100 per year for glasses or contacts. Weight Watchers Membership: Enrollees can go to Weight Watchers for free. Weight Watchers helps people lose weight

8 Enrollee Rights CCAI Enrollees have the right to: Be treated with dignity and respect Privacy Receive quality health care Receive an explanation of their illness Receive an explanation of their treatment options Share in deciding the type of care they will receive. Persons under 18 who are married, pregnant, or have a child also have this right. Refuse health care (to the extent of the Law) and understand what may happen if they do Ask for a summary of their records Request that their medical records be changed Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation To be free to exercise these rights and the exercise of these rights does not adversely affect the way CCAI treats enrollees Make a Living Will Enrollee Responsibilities CCAI Enrollees have the responsibility to: Treat Enrollees of their Care Team with dignity and respect Make and keep appointments and be on time. Call if they need to cancel an appointment or if they will be late. Get referrals from their CCAI doctor Notify CCAI as soon as possible after receiving emergency room services Explain their health problem and symptoms to the doctor and to ask questions Follow their doctor s treatment plan Discuss with their doctor anything that could keep them from following his or her instructions Become involved in their health care Consider the outcome of refusing treatment Learn and follow the CCAI policies in their Enrollee Handbook Carry their CCAI Enrollee ID Card with them at all times Report any lost or stolen cards to CCAI Enrollee Services Call Enrollee Services if they need help Respect the privacy of other people waiting for health care services Reporting Abuse, Neglect, Exploitation, or Unusual Incidents You can contact the Department of Public Health to get information on CNAs, or the Department of Financial and Professional Regulation for information on any LPN or RN that you want to employ to see if they have allegations of abuse, neglect or theft. If you are the victim of abuse, neglect or exploitation, you should report this to your Community Care Alliance of Illinois (CCAI) Case Manager right away. You should also report the issue to one of the following agencies based on your age or placement. All reports to these agencies are kept confidential and anonymous reports are accepted. Nursing Home Hotline Illinois Department of Public Health Nursing Home Hotline is for reporting complaints regarding hospitals, nursing facilities, and home health agencies and the care or lack of care of the patients. Office of the Inspector General The Illinois Department of Human Services Office of Inspector General Hotline is to report allegations of abuse, neglect, or exploitation for people 18 to 59 years old. Aging/Elder Abuse (TTY ) The Illinois Department on Aging Elder Abuse Hotline is to report allegations of abuse, neglect, or exploitation for people 60 years old and over. Your Community Care Alliance of Illinois (CCAI) Case Manager will provide you with 2 brochures on reporting Elder Abuse and Exploitation. You can request new copies of these brochures at any time

9 Illinois law defines abuse, neglect, and exploitation as: Physical abuse Inflicting physical pain or injury upon a senior or person with disabilities. Sexual abuse Touching, fondling, intercourse, or any other sexual activity with a senior or person with disabilities, when the person is unable to understand, unwilling to consent, threatened or physically forced. Emotional abuse Verbal assaults, threats of abuse, harassment, or intimidation. Confinement Restraining or isolating the person, other than for medical reasons. Passive neglect The caregiver s failure to provide a senior or person with disabilities with life s necessities, including, but not limited to, food, clothing, shelter or medical care. Willful deprivation Willfully denying a senior or person with disabilities medication, medical care, shelter, food, a therapeutic device or other physical assistance, and thereby exposing that adult to the risk of physical, mental, or emotional harm except when the person has expressed an intent to forego such care. Financial exploitation The misuse or withholding of a senior or person with disabilities resources to the disadvantage of the person or the profit or advantage of someone else. Disenrollment Procedures If you would like to disenroll, please call our Enrollee Services Department at We would like to know if there is anything we can help you with. To disenroll or change medical plans, contact the State Client Enrollment Services at Advance Directives (Living Will) This is how you can express your wishes (if something were to happen to you). It is a legal paper to write down what medical care you want. If you have questions, call Enrollee Services at Integrated Care Program - Grievances and Appeals We want you to be happy with services you get from Community Care Alliance of Illinois (CCAI) and our providers. If you are not happy, you can file a grievance or appeal. Grievance A grievance is a complaint about any matter other than a denied, reduced or terminated service or item. CCAI takes Enrollee grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. CCAI has special procedures in place to help Enrollees who file grievances. We will do our best to answer your questions or help to resolve your concern. Filing a grievance will not affect your health care services or your benefits coverage. 16 These are examples of when you might want to file a grievance. Your provider or a CCAI staff member did not respect your rights. You had trouble getting an appointment with your provider in an appropriate amount of time. You were unhappy with the quality of care or treatment you received. Your provider or a CCAI staff member was rude to you. Your provider or a CCAI staff member was insensitive to your cultural needs or other special needs you may have. 17

10 You can make your grievance on the phone by calling CCAI at You can also file your grievance in writing via mail or fax at: Community Care Alliance of Illinois Attn: Grievance and Appeals Department 322 S. Green Street, Suite 400 Chicago, IL Fax: In the grievance letter, give us as much information as you can. For example, include the date and place the incident happened, the names of the people involved and details about what happened. Be sure to include your name and your Enrollee ID number. You can ask us to help you file your grievance by calling If you do not speak English, we can provide an interpreter at no cost to you. Please include this request when you file your grievance. If you are hearing impaired, call the Illinois Relay at 711. At any time during the grievance process, you can have someone you know represent you or act on your behalf. The person will be your representative. If you decide to have someone represent you or act for you, inform CCAI in writing the name of your representative and his or her contact information. We will try to resolve your grievance right away. If we cannot, it will go to our Grievance Committee. We may contact you for more information. The Grievance Committee will make a recommendation within sixty (60) calendar days from the date you filed your grievance. You will get a letter from CCAI with our resolution. Appeals You may not agree with a decision or an action made by CCAI about your services or an item you requested. An appeal is a way for you to ask for a review of our actions. You may appeal within sixty (60) calendar days of the date on our Notice of Action form. If you want your services to stay the same while you appeal, you must say so when you appeal, and you must file your appeal not later than ten (10) calendar days from the date on our Notice of Action form. The list below includes examples of when you might want to file an appeal. Not approving or paying for a service or item your provider asks for Stopping a service that was approved before Not giving you the service or items in a timely manner Not advising you of your right to freedom of choice of providers Not approving a service for you because it was not in our network If we decide that a requested service or item cannot be approved, or if a service is reduced, stopped or ended, you will get a Notice of Action letter from us. This letter will tell you the following: What action was taken and the reason for it Your right to file an appeal and how to do it Your right to ask for a State Fair Hearing and how to do it Your right in some circumstances to ask for an expedited appeal and how to do it Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services Here are two ways to file an appeal. 1) Call Enrollee Services at If you file an appeal over the phone, you must follow it with a written signed appeal request. Mail or fax your written appeal request to the address below. 2) Mail or fax Community Care Alliance of Illinois Attn: Grievance and Appeals Department 322 S. Green Street, Suite 400 Chicago, IL Fax: If you do not speak English, we can provide an interpreter at no cost to you. Please include this request when you file your appeal. If you are hearing impaired, call the Illinois Relay at

11 Can someone help me with the appeal process? You have several options for assistance. You may: Ask someone you know to assist in representing you. This could be your Primary Care Physician or a family member, for example. Choose to be represented by a legal professional. If you are in the Disabilities Waiver, Traumatic Brain Injury Waiver, or HIV/AIDS Waiver you may also contact CAP (Client Assistance Program) to request their assistance at (Voice) or (TTY). To appoint someone to represent you, 1) send us a letter telling us that you want someone else to represent you and include in the letter his or her contact information or, 2) fill out the Authorized Representative Appeals form. You may find this form on our website at: Appeals Process We will send you an acknowledgement letter within three (3) business days saying we received your appeal. We will tell you if we need more information and how to give us such information in person or in writing. A provider with the same or similar specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce or stop the medical service. CCAI will send our decision in writing to you within fifteen (15) business days of the date we received your appeal request. CCAI may request an extension up to fourteen (14) more calendar days to make a decision on your case if we need to get more information before we make a decision. You can also ask us for an extension, if you need more time to obtain additional documents to support your appeal. We will call you to tell you our decision and send you and your authorized representative the Decision Notice. The Decision Notice will tell you what we will do and why. If CCAI s decision agrees with the Notice of Action, you may have to pay for the cost of the services you got during the appeal review. If CCAI s decision does not agree with the Notice of Action, we will approve the services to start right away. Things to keep in mind during the appeal process: At any time, you can provide us with more information about your appeal, if needed. You have the option to see your appeal file. You have the option to be there when CCAI reviews your appeal. How can you expedite your Appeal? If you or your provider believes our standard timeframe of fifteen (15) business days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal by writing or calling us. If you write to us, please include your name, Enrollee ID number, the date of your Notice of Action letter, information about your case and why you are asking for the expedited appeal. We will let you know within twenty-four (24) hours if we need more information. Once all information is provided, we will call you within twenty-four (24) hours to inform you of our decision and will also send you and your authorized representative the Decision Notice. How can you withdraw an Appeal? You have the right to withdraw your appeal for any reason, at any time, during the appeal process. However, you or your authorized representative must do so in writing, using the same address as used for filing your appeal. Withdrawing your appeal will end the appeal process and no decision will be made by us on your appeal request. CCAI will acknowledge the withdrawal of your appeal by sending a notice to you or your authorized representative. If you need further information about withdrawing your appeal, call CCAI at What happens next? After you receive the CCAI appeal Decision Notice in writing, you do not have to take any action and your appeal file will be closed. However, if you disagree with the decision made on your appeal, you can take action by asking for a State Fair Hearing Appeal and/or asking for an External Review of your appeal within thirty (30) calendar days of the date on the Decision Notice. You can choose to ask for both a State Fair Hearing Appeal and an External Review or you may choose to ask for only one of them

12 State Fair Hearing If you choose, you may ask for a State Fair Hearing Appeal within thirty (30) calendar days of the date on the Decision Notice, but you must ask for a State Fair Hearing Appeal within ten (10) calendar days of the date on the Decision Notice if you want to continue your services. If you do not win this appeal, you may be responsible for paying for these services provided to you during the appeal process. At the State Fair Hearing, just like during the CCAI Appeals process, you may ask someone to represent you, such as a lawyer or have a relative or friend speak for you. You can ask for a State Fair Hearing in one of the following ways: Your local Family Community Resource Center can give you an appeal form to request a State Fair Hearing and will help you fill it out, if you wish. If you want to file a State Fair Hearing Appeal related to your medical services or items, or Elderly Waiver (Community Care Program (CCP)) services, send your request in writing to: Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings 401 S Clinton Street, 6th Floor Chicago, IL Fax: (312) Or you may call (855) , TTY: (800) If you want to file a State Fair Hearing Appeal related to Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/ AIDS Waiver services, or any Home Services Program (HSP) service, send your request in writing to: Illinois Department of Human Services Bureau of Hearings 401 S Clinton Street, 6th Floor Chicago, IL Fax: (312) Or you may call (800) , TTY: (877) State Fair Hearing Process The hearing will be conducted by an Impartial Hearing Officer authorized to conduct State Fair Hearings. You will receive a letter from the appropriate Hearings office informing you of the date, time and place of the hearing. This letter will also provide information about the hearing. It is important that you read this letter carefully. At least three (3) business days before the hearing, you will receive information from CCAI. This will include all evidence we will present at the hearing. This will also be sent to the Impartial Hearing Officer. You must provide all the evidence you will present at the hearing to CCAI and the Impartial Hearing Officer at least three (3) business days before the hearing. This includes a list of any witnesses who will appear on your behalf, as well as all documents you will use to support your appeal. You will need to notify the appropriate Hearings Office of any accommodation you may need. Your hearing may be conducted over the phone. Please be sure to provide the best phone number to reach you during business hours in your request for a State Fair Hearing. The hearing may be recorded. Continuance or Postponement You may request a continuance during the hearing, or a postponement prior to the hearing, which may be granted if good cause exists. If the Impartial Hearing Officer agrees, you and all parties to the appeal will be notified in writing of a new date, time and place. The time limit for the appeal process to be completed will be extended by the length of the continuation or postponement. Failure to Appear at the Hearing Your appeal will be dismissed if you, or your authorized representative, do not appear at the hearing at the time, date and place on the notice and you have not requested postponement in writing. If your hearing is conducted via telephone, your appeal will be dismissed if you do not answer your telephone at the scheduled appeal time. A Dismissal Notice will be sent to all parties to the appeal. Your hearing may be rescheduled, if you let us know within ten (10) calendar days from the date you received the Dismissal Notice, if the reason for your failure to appear was: A death in the family Personal injury or illness which reasonably would prohibit your appearance A sudden and unexpected emergency 23

13 If the appeal hearing is rescheduled, the Hearings Office will send you or your authorized representative a letter rescheduling the hearing with copies to all parties to the appeal. If we deny your request to reset your hearing, you will receive a letter in the mail informing you of our denial. The State Fair Hearing Decision A Final Administrative Decision will be sent to you and all interested parties in writing by the appropriate Hearings Office. This Final Administrative Decision is reviewable only through the Circuit Courts of the State of Illinois. The time the Circuit Court will allow for filing of such review may be as short as thirty-five (35) days from the date of this letter. If you have questions, please call the Hearing Office. External Review (for medical services only) Within thirty (30) calendar days after the date on the CCAI appeal Decision Notice, you may choose to ask for a review by someone outside of CCAI. This is called an external review. The outside reviewer must meet the following requirements: Board certified provider with the same or like specialty as your treating provider Currently practicing Have no financial interest in the decision Not know you and will not know your identity during the review External Review is not available for appeals related to services received through the Elderly Waiver; Persons with Disabilities Waiver; Traumatic Brain Injury Waiver; HIV/Aids Waiver; or the Home Services Program. What Happens Next? We will review your request to see if it meets the qualifications for external review. We have five (5) business days to do this. We will send you a letter letting you know if your request meets these requirements. If your request meets the requirements, the letter will have the name of the external reviewer. You have five (5) business days from the letter we send you to send any additional information about your request to the external reviewer. The external reviewer will send you and/or your representative and CCAI a letter with their decision within five (5) calendar days of receiving all the information they need to complete their review. Expedited External Review If the normal time frame for an external review could jeopardize your life or your health, you or your representative can ask for an expedited external review. You can do this over the phone or in writing. To ask for an expedited external review over the phone, call Enrollee Services toll-free at To ask in writing, send us a letter at the address below. You can only ask one (1) time for an external review about a specific action. Your letter must ask for an external review of that action. Community Care Alliance of Illinois Attn: Grievance and Appeals Department 322 S. Green Street Chicago, IL Fax: Your letter must ask for an external review of that action and should be sent to: Community Care Alliance of Illinois Attn: Grievance and Appeals Department 322 S. Green Street Chicago, IL Fax:

14 What happens next? Once we receive the phone call or letter asking for an expedited external review, we will immediately review your request to see if it qualifies for an expedited external review. If it does, we will contact you or your representative to give you the name of the reviewer. We will also send the necessary information to the external reviewer so they can begin their review. As quickly as your health condition requires, but no more than two (2) business days after receiving all information needed, the external reviewer will make a decision about your request. They will let you and/or your representative and CCAI know what their decision is verbally. They will also follow up with a letter to you and/or your representative. CCAI Contact Information: Enrollee Services: 322 South Green Street Chicago, IL TTY for the Hearing Impaired: Website: