Are you a client or a caregiver working with someone or a family member that receives home care services through the Medicaid waiver (Community Health Choices) in Pennsylvania? Does your client have a need for additional hours but don’t know where to start? Alternatively, did your have a set number of home care caregiver assigned hours that were cut? Find out the process on how one can go about getting more hours below, whether you’ve recently been denied for additional hours, or want to know where to begin.
Note: This guide is for those individuals currently on the Community Health Choices Medicaid waiver program and with one of the three health plans serving those members in Pennsylvania, including Keystone First, PA Health and Wellness, Amerihealth Caritas, and UPMC. If you are not yet on the Medicaid waiver program, also known as Community Health Choices, read our guide here on how to get started on getting home care services in Pennsylvania.
If at any time you have questions about this process, feel free to reach out to the Chosen Family Home Care team and contact us here. Chosen Family Home Care partners with participants to make sure to help provide them with the education and knowledge to get their care. We can help guide participants that are a part of the organization to help them through this challenging time.
Click below to navigate directly to your particular situation:
Tips For Requesting More Hours and Fighting Denials
How Chosen Family Home Care Can Help
My Hours Increase Request Was Denied, Or My Hours Were Cut
Situation 1: I am currently receiving home care services under Community HealthChoices through Keystone First, Amerihealth Caritas, UPMC, or PA Health and Wellness. I have an approved number of hours, and I requested more but that request was denied.
Step One
Most likely, either your designated Service Coordinator or a member of the health plan authorization team will reach out to you to let you know of the denial or your cut in hours. Your home care agency, such as if you were with Philly’s top agency Chosen Family Home Care , will likely get notified. Sometimes, the home care agency will know about the cut in home care hours or hours increase denial before the participant. Also, the health plans are required to notify the participants and the home care agency as well via USPS post office mail.
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The top home care agencies can help walk those in need through this process. Chosen Family Home Care is proud to be an advocate for our clients and caregivers. Contact Chosen Family today to find a true partner in care for your home care services that is willing and able to advocate for you.
Step Two
You will be formally notified about the appeals/grievance process. An appeal is what you will file if you do not agree with your health plan’s decision. How you proceed will depend on which health plan you have. We will focus on Keystone First appeals and grievances as well as PA Health and Wellness and UPMC, as they are the most common CHC insurance plans in Pennsylvania as well as Philadelphia.
Step Three (Keystone First)- For PA Health and Wellness process, proceed to the next step below
What is Keystone First’s phone number for complaints?
Call Keystone First CHC at 1-855-332-0729 (TTY 1-855-235-4976) and tell Keystone First CHC your Complaint, or
• Write down your Complaint and send it to Keystone First CHC by mail or fax, or
• If you received a notice from Keystone First CHC telling you Keystone First CHC’s decision and the notice included a Complaint/Grievance Request Form,
fill out the form and send it to Keystone First CHC by mail or fax.
What is Keystone First’s fax number for complaints?
You can use Keystone First CHC’s address and fax number for Complaints and Grievances:
Keystone First CHC
Participant Appeals
200 Stevens Drive
Philadelphia, PA 19113-1570
Fax number: 1-855-332-0141
There are time limits on it, but for standard appeals/complaints/grievances, the time period for submission is 60 days.
You can read all about Keystone First complaints and grievances right here in their Keystone First complaints and grievances manual. The manual goes over the full process for appeals, grievances, and complaints, including all of the complaint tiers as well as further appeals and grievance processes.
For example, after two complaints, one can then escalate the matter for an external complaint review. This can be filed with the following:
Pennsylvania Insurance Department
Bureau of Consumer Services
1209 Strawberry Square
Harrisburg, PA 17120
Fax: 717-787-8585
You can even file a complaint with the Pennsylvania Insurance Department online at this link!
What to do to continue getting services:
If you have been getting the services or items that are being reduced, changed or denied and you want to continue getting services, you must ask for an external Complaint review or a Fair Hearing within 10 days of the date on the notice telling you Keystone First CHC’s First Level Complaint decision that you cannot get services or items you have been receiving because they are not covered services or items for you for the services or items to continue until a decision is made. If you will be asking for both an external Complaint review and a Fair Hearing, you must request both the external Complaint review and the Fair Hearing within 10 days of the date on the notice telling you Keystone First CHC’s First Level Complaint decision. If you wait to request a Fair Hearing until after receiving a decision on your external Complaint, services will
not continue.
Fair hearings
In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something Keystone First CHC did or did not do. These hearings are called “Fair Hearings.” You can ask for a Fair Hearing after Keystone First CHC decides your First Level Complaint or decides your Grievance.
How Do I Ask for a Fair Hearing?
Your request for a Fair Hearing must be in writing. You can either fill out and sign the Fair Hearing Request Form included in the Complaint or the Grievance decision notice
or write and sign a letter.
If you write a letter, it needs to include the following information:
Your (the Participant’s) name and date of birth;
A telephone number where you can be reached during the day;
Whether you want to have the Fair Hearing in person or by telephone;
The reason(s) you are asking for a Fair Hearing; and
A copy of any letter you received about the issue you are asking for a Fair Hearing about.
You must send your request for a Fair Hearing to the following address:
Department of Human Services
OLTL/Forum Place 6th FL
CHC Complaint, Grievance and Fair Hearings
P.O. Box 8025
Harrisburg, PA 17105-8025
Step Four (PA Health and Wellness)
PA Health and Wellness Community Health Choices will follow a similar process as Keystone First. The major difference is where and how to file a complaint or grievance.
You may file a complaint or grievance via phone, fax, email or mail to UPMC one of the following ways:
-
- Call 1-844-833-0523
- Fax 1-844-873-7451
- Write and mail to PA Health & Wellness, Attention Complaint and Grievance Unit, 300 Corporate Center Drive, Camp Hill, PA 17011
Step Five (UPMC)
Similarly to the other two plans mentioned, UPMC Community Health Choices will follow a similar process as Keystone First.
A Grievance is when you tell UPMC Community Health Choices that you disagree with UPMC Community Health Choices’ decision to cut your home care services (or deny a request for additional hours). You may file a complaint or grievance via phone, fax or mail for UPMC one of the following ways:
- Call 1-844-626-6813
- Fax 412-454-7920
- Email UPMCCHC@upmc.edu
- Write and mail to:
- UPMC Community HealthChoices
Complaints, Grievances, and Appeals
PO Box 2939
Pittsburgh, PA 15230-2939
- UPMC Community HealthChoices
