Grievance and Appeals
DEPARTMENT OF SOCIAL SERVICES / CONNECTICUT DENTAL HEALTH PARTNERSHIP – Hearing Process.
Request for Goods or Services
Some dental services need to be approved before the HUSKY programs will pay for them. This is called prior authorization (PA). Your dentist must be part of the Connecticut Medical Assistance Program in order to ask for PA for you or your children. The person getting the service for which the dentist is asking for PA must be eligible for HUSKY when the dentist makes the PA request and when the service is provided.
Review of PA Request
Once your dentist asks for PA, a Connecticut Dental Health Partnership (CTDHP) dentist reviews it. The CTDHP will send a notice to your dentist telling him or her that the PA was approved or denied. Sometimes the CTDHP dentist needs more information from your dentist before a decision can be made on the PA. These requests will be pended until the information needed to make the decision is provided. If the requested good or service is not covered or is not medically necessary, the CTDHP will deny the request for PA. The notice will tell your dentist why the PA was denied. It will also tell your dentist how to appeal the denial.
Notice of Action
If a service your dentist requested for you is denied, the CTDHP will send you a Notice of Action (NOA). The letter will tell you why the service was denied. It will also tell you about your right to appeal and will include a Hearing Request Form.
Request for a Hearing
If you wish to appeal the denial, you must complete and send the Hearing Request Form to the Department of Social Services (DSS). You must mail or fax the form to DSS within 60 days of the date of the NOA. DSS will try to schedule your hearing within 30 days from the date it receives your hearing request form. If you have a condition that needs attention right away, such as severe pain or an infection, you can ask to have your hearing more quickly. To request an expedited hearing, check the box on the hearing request form. CTDHP will let you know if your request can be expedited within 2 days of receiving the request. If you need interpreter services for the hearing, check the box that asks about that on the hearing request form. Please state the type of interpreter service you need. DSS will arrange for an interpreter to attend the hearing to translate for you. Staff and family members under the age of 18 may not translate for you at the hearing.
Notice of Hearing
DSS will send you a hearing notice telling you the date, time, and place of your hearing. The notice will also tell you the name of the Hearing Officer who will hear your case. If you cannot go to the hearing at the date or time on the notice, you must call DSS and ask for a new hearing date. The notice tells you who to call if you cannot get to the hearing. If you have not called to change your hearing date and you are not at the hearing, your appeal may be dismissed.
CTDHP Appeal Process
If you appeal the PA denial, a CTDHP dentist who did not deny your request for PA will review your case again. This dentist will make a decision about your case based on written documents that CTDHP has on your case. You may also ask to meet with this dentist or send in additional documents or written materials. Many times, the PA is approved during this second review because your dentist sent in more information about your condition.
If CTDHP approves the PA request after reviewing your case again, you may wish to withdraw your request for a hearing with DSS. CTDHP will join you in a phone call to DSS so that you may withdraw your request for a hearing. DSS will send you a letter after the phone call, asking you to confirm that you no longer want a hearing.
DSS Hearing Process
If the CTDHP appeal does not change the denial of PA, the hearing with DSS will go forward. CTDHP will send a summary about your case to you and the Hearing Officer assigned to your case approximately five days before the hearing date. You also have the right to review all the documents that CTDHP reviewed when it denied the PA.The Hearing Officer, the DSS Dental Consultant, a representative of CTDHP, you and anyone you bring with you are present at the hearing. You also may have a lawyer represent you at the hearing. The Hearing Officer is always located at the DSS central office in Hartford. You and anyone you bring with you and the CTDHP representative are in the DSS regional office. The Dental Consultant joins the hearing via telephone. The Hearing Officer conducts the hearing via video cam. An audiotape is used to record all testimony. Only an audio recording of the hearing is kept for the record.
The hearing officer issues a written decision within approximately 90 days from the date of the hearing request. DSS sends you the decision via Signature Confirmation. If you disagree with the hearing officer’s decision, you may ask DSS for reconsideration. You may also appeal to the Connecticut Superior Court. Information about the time frames for filing a request for reconsideration and an appeal to Superior Court is included with the hearing officer’s decision.