If you need to appeal a decision made by your LME/MCO, you should request your (or your child’s) case file for the last 2 to 3 years (as long as you have had the disputed services during that time). The LME/MCO cannot charge you for the file. Below is a template you can use to make the request. Copy the language that follows into an email to the LME/MCO. There should be a phone number on the denial(s) for the Appeals Department at the LME/MCO. Call that number and ask them where to direct your email. We suggest you also copy your Care Coordinator on this email.
I am appealing the denial of (type of services) for (Name of beneficiary) and requesting a complete copy of (his/her/my) case file for the past three years. At a minimum, this should include all documents identified in peer reviews, as well as care coordination notes, clinical rationales, internal review forms, medication review consultation forms, reconsideration referral, Reconsideration Peer Review form 3, clinical assessments, LME/MCO correspondence with reviewers, budget information, information related to Intensive Review, medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits, etc.
This is not intended to be an exhaustive list. I do not know the names of all of the documents that may be in (Name’s) file. I am requesting the entire file (he/she or I am) is entitled to under federal law in order to allow (him/her/me) to adequately prepare for this appeal. In an effort to reduce the amount of paperwork, I am requesting (his/her/my) files for the last three years and that the files be sent to me electronically. Thank you for your prompt response.