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MEMBER RESOURCES > APPEALS OR EXCEPTIONS

Appoint a representative, file a grievance or appeal,
request a coverage determination, and more.

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File an Appeal

 

File a standard or expedited (fast) appeal over the phone or in writing to:

Fax: 1-833-610-2380

Mail:

Align Senior Care
Appeals and Grievances Department
PO Box 40
Glen Burnie, MD 21060

What happens next?

We will review your appeal and send you a decision:

  • Fast (expedited) Pre-Service appeals: within 72 hours
  • Standard Pre-Service appeals: within 30 days
  • Payment appeals: within 60 days

If we do not approve your request, your case may be sent to an independent reviewer outside of Align Senior Care. You will receive instructions on next steps and your rights.

What is an appeal?

An appeal is a request to review a decision we made about your care or coverage. If you disagree with a denial or payment decision, you can ask us to look at it again.

Examples include:

  • We do not approve part or all of a service, item, or Part B drug
  • We do not pay for a claim
Who can file an appeal?

An appeal may be filed by:

  • You (the member)
  • Your authorized representative
  • Your doctor or provider (depending on the situation)
  • A legal representative, if applicable
Why file an appeal?

You should file an appeal if you believe a decision about your care, service, or payment should be changed. This helps ensure you receive the benefits and coverage you are entitled to.

When to file an appeal?

You must file an appeal within 60 calendar days of the date on your denial notice.

  • Standard appeals must be submitted in writing
  • Fast (expedited) appeals can be requested by phone or in writing
  • If you miss the deadline, you may still file if you have a good reason

Examples of a good reason may include:

  • You did not receive your notice, or you received it late
  • You were seriously ill
  • There was a death or serious illness in your immediate family
  • Important records were lost or destroyed (for example, in an accident)
  • You had trouble getting the information you needed in time
  • You were given incorrect or incomplete information about how to appeal
  • You were not able to understand the deadline
  • If you do not have a good reason for missing the deadline, your request may be dismissed

Can I request a fast (expedited) appeal?

Yes. You can request a fast appeal if your health requires a quicker decision.

  • You, your doctor, or your representative can request it
  • We will review your request quickly if your condition requires it
  • You will receive a decision within 72 hours if approved
I disagree with the appeal decision. Where can I reconsideration be filed?

Click here to view how you can request a reconsideration

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