VIII. Re-Determination Denials and Appeals

Substance Abuse and Mental Health Menu

If the EEU has determined that an individual is no longer in need of long term behavioral healthcare, the disenrollment decision will be made by an EEU physician. The EEU will issue a disenrollment letter which will include an explanation of the bases for disenrollment and will include the Eligibility Determination Summary with this letter. The primary service provider or the enrollee has the right to resubmit the disenrollment request within ten (10) working days or to appeal the decision. If the provider or the consumer chooses to appeal the decision, a written appeal must be filed with the DSAMH Deputy Director or designee within five (5) working days of the notification of determination. DSAMH will issue a response to appeals within five (5) working days; a disenrollment decision which is upheld is subject to a second level appeal.

For Medicaid enrolled consumers, the second level appeal will be heard by the Division of Social Services.

VIII. Re-Determination Denials and Appeals

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