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Filing an Appeal

Appeal Process

An appeal is a request to review an adverse benefit determined by Sunflower. An adverse benefit determination is the denial, limiting of a member service, or failure by Sunflower to provide service timely or to act within timeframes. An appeal of an adverse benefit determination is a request for Sunflower to review the determination of concern, existing or additional documentation, and make an appeal decision. You can request this review by phone or in writing. You may not appeal a payment issue for a provider. If you are receiving a bill from a provider, please contact Sunflower.

Appeal Basics

  • Sunflower will not treat you differently if you file an appeal.
  • An appeal must be filed within 60 calendar days of the date of the letter noting an adverse benefit determination that is sent to you. 3 additional calendar days will be allowed for mailing time. This letter may be called “Notice of Adverse Benefit Determination.” If you receive a letter and you don’t know if it is an adverse benefit determination letter, please contact us to review it with you.
  • An appeal may be filed by phone, fax, or in writing.
  • Information on how to appeal will be included in the adverse benefit determination letter you receive.
  • You may allow someone including an attorney, family member, provider or other authorized representative to file an appeal for you. To do so you must sign a form giving that person permission to act on your behalf. This form will be included in the letter you receive explaining your appeal rights, or can be found by contacting Customer Service or from the Sunflower website by clicking here. You will need to fill it out and return it by mail or fax before Sunflower can review your concern with the person you designate.
  • Information or documents that support the appeal can be sent to Sunflower by mail or fax.
  • Sunflower will provide assistance in filling out any forms needed for the process.
  • For appeals related to services that put your health at immediate risk, you may file an expedited appeal. These will be reviewed within 72 hours of the request. These can be submitted verbally and do not have to be in writing to Sunflower. To get an expedited appeal, please call Sunflower at 1-877-644­-4623. Sunflower will make reasonable effort to call you with the appeal decision. A member may not file a State Fair Hearing at the same time as an expedited appeal. If the appeal is found not to put the member health at immediate danger, it may be changed to a standard appeal. Reasonable effort will be made to notify verbally that the expedited appeal will be handled in standard timeframe. Written notice acknowledging appeal as standard will be sent within 2 calendar days and the appeal will be resolved in 30 calendar days.
  • A State Fair Hearing may be requested once the member has completed the internal process of Sunflower appeal. State Fair Hearing requests must be made within 120 calendar days of the letter notifying of the decision on your appeal by Sunflower. 3 additional calendar days will be allowed for mailing time.
  • You have the right to have a representative of your choice at the State Fair Hearing. You will receive the rules that govern representation at a State Fair Hearing in the appeal resolution letter you receive.
  • A Fair Hearing includes Sunflower as well as you and your representative, or the representative of a deceased member’s estate.
  • Sunflower wants to resolve your concerns quickly, and will resolve your appeal within 30 calendar days of you filing it with us. If we cannot resolve your appeal in the timeframes noted, we can request to extend the timeframe by up to 14 calendar days to gather more information to assist you. You or your provider can also ask for an extension. If an extension is needed, we will notify you in writing of the reason we need more time to resolve your concern. Requests for extensions must be made 2 business days before the 30 calendar day deadline to the state.

Where to Send Your Appeal:

Please send appeal requests to the address in your adverse benefit determination letter. That address is below:

Sunflower Health Plan Quality Department
8325 Lenexa Drive, Suite 200
Lenexa, KS 66214
Phone: 1-877-644-4623, TTY 711
Fax: 1-888-453-4755

What Happens to my Services While I am Appealing the Action? 

Continuation of Non-HCBS Services: Services may be continued during the appeal or State Fair Hearing if all of the following criteria are met:

  1. Sunflower Health Plan’s action reduces, suspends or terminates previously authorized services.
  2. Request for appeal or state fair hearing is filed timely along with request for continuation of benefits, within 10 calendar days from the date the notice of adverse benefit determination was mailed or within 10 calendar days of the date the reduction, suspension, or termination of previously authorized services goes into effect.
  3. The services were ordered by authorized provider.
  4. The original period covered by the authorization has not expired.

For members who are receiving Non-HCBS Services, if the decision of the appeal or State Fair Hearing is not in the member’s favor and Sunflower’s decision is upheld, then Sunflower may recover the costs of the services provided to the member while the appeal or State Fair Hearing was in process from the member.

For members who receive Non-HCBS services, the services and benefits continued pending the outcome of the appeal process shall end 10 calendar days following the notice containing the appeal decision for the termination, suspension or reduction of previously authorized services. If a state fair hearing and request for continuation of benefits is requested within 10 calendar days from the date on the notice of the appeal decision, the services and benefits will be continued through the date of the State Fair Hearing decision.

Continuation of HCBS Services will be continued during the appeal or State Fair Hearing process if all of the following criteria are met:

  1. Sunflower Health Plan’s action reduces, suspends or terminates previously authorized HCBS Program services or benefits.
  2. Request for appeal is filed timely within 60 calendar days from the date of the notice of adverse benefit determination. 3 additional calendar days will be allowed for mailing time. Or in the case of a State Fair Hearing, the request for State Fair Hearing is filed timely within 120 calendar days from the date of the notice of appeal resolution. 3 additional calendar days will be allowed for mailing time.
  3. The services were ordered by authorized provider.
  4. The original period covered by the authorization has not expired.
  5. If you requested different HCBS Program services to replace your previously authorized HCBS Program services, and Sunflower Health Plan authorized the new HCBS Program services, your previously authorized HCBS Program services must be terminated to allow your new HCBS Program services to begin.  If your new HCBS Program services will begin within 63 days of the date of the Notice of Adverse Benefit Determination terminating your previously authorized HCBS Program services, your previously authorized HCBS Program services will be continued only until your new HCBS Program services begin.

For members who are receiving HCBS Services, if the decision of the appeal or State Fair Hearing is not in the member’s favor and Sunflower’s decision is upheld, the member will not have to pay Sunflower for the HCBS services and benefits provided during the appeal or State Fair Hearing was in process unless fraud has occurred.

For members who receive HCBS services, the services and benefits continued pending the outcome of the appeal process shall end 123 calendar days following the notice containing the appeal decision for the termination, suspension or reduction of previously authorized services. If a State Fair Hearing is requested within 123 calendar days from the date on the notice of the appeal decision, the services and benefits will be continued through the date of the State Fair Hearing decision.

Benefits will continue during the appeal or State Fair Hearing process until one of the following happens:

  1. Member withdraws the appeal.
  2. Member does not request appeal within 60 calendar days from the date on the notice of adverse benefit determination, or does not request State Fair Hearing within 120 calendar days from date on the appeal resolution notice. 3 additional calendar days will be allowed for mailing time.
  3. State Fair Hearing officer issues hearing decision that is not in favor of the member.
  4. Time period or service limits of previously authorized service has been met.
  5. Member or member guardian requests previously authorized HCBS services or benefits to end and be replaced with another HCBS service or benefit.

Requests for future services are not included under continuation of benefits.

If you do not know if the services you are receiving are Home and Community Based Services (HCBS), please contact Customer Service at 1-877-644­-4623.

Appeal Process Timeline:

  • Step 1: Member files appeal by calling Customer Service, or by sending a fax or letter to Sunflower within 60 calendar days of the date on the notice of adverse benefit determination. 3 additional calendar days will be allowed for mailing time.
  • Step 2: Member may request to have services continue while they are waiting for Sunflower to make a decision, but this request must be made in 10 calendar days from the mailing date on the notice of action letter for continuation of non-waiver services.  For HCBS services, services provided will continue without change until the appeal process is complete.
  • Step 3: Sunflower sends a letter within 5 calendar days of the receipt of the appeal to let member know the appeal has been received.
  • Step 4: Sunflower will resolve the appeal and send the member a notice of their decision within 30 calendar days of receipt of the appeal.
  • Step 5: If a member is not satisfied with the Sunflower appeal decision they have the right to request a State Fair Hearing within 120 days of the date on notice of appeal resolution. 3 additional calendar days will be allowed for mailing time. If members want their non-HCBS services to be continued during the State Fair Hearing, they must request a state fair hearing and continuation of benefits within 10 calendar days of the date the notice of appeal resolution was mailed. HCBS services will continue without change until the State Fair Hearing is complete.

 

ADDITIONAL RESOURCE: KANCARE OMBUDSMAN

The KanCare Ombudsman is employed by the State of Kansas Department for Aging and Disability Services (KDADS) and is available to assist KanCare members regarding their rights and responsibilities under KanCare. The Ombudsman helps KanCare/Medicaid member and Kansas Consumers with concerns about getting services needed through KanCare which includes providing assistance to those served on the Home and Community Based Services (HCBS) waiver programs and those who get long-term care through KanCare.  The Ombudsman can help you:

  • When you need help with a problem you can’t solve by speaking with your KanCare health plan.
  • When you do not think that you are getting the care that you need.
  • When you feel your rights are being violated.
  • When you feel you have not received culturally appropriate care.

You can reach the KanCare Ombudsman at 1-855­ 643-8180, TTY 711, or by email at KanCare.Ombudsman@kdads.ks.gov.