If You Disagree With a Decision
You have the right to appeal decisions that are made about your health benefits. You may file an internal appeal and/or a fair hearing. An internal appeal is review by a qualified person who was not involved in the original decision. A fair hearing is a legal proceeding in which an impartial hearing officer will review the decision.
To File an Internal Appeal or Fair Hearing
Call 1(800) 250-8427.
If the decision you received is to reduce or end benefits or services you are currently getting and you want your benefits or services to continue during your appeal, you must request this at the time you make your appeal. If you get benefits or services during your appeal, you may be asked to pay for them if the appeal is not decided in your favor.
How Internal Appeals Work
You have 90 days from the decision date to file an internal appeal. If you prefer, your provider may ask for the appeal. Appeals will be decided within 45 days of when the department receives your appeal. This may be extended up to 59 days if it is to your advantage.
Emergency expedited appeals may be requested in situations when you or your doctor believe(s) that the time frame of a regular appeal could cause serious risk to your health or your life. To file an emergency (expedited) appeal , call Green Mountain Care Member Services at: 1(800) 250-8427.
If you are told that your benefit is changed because of a change in federal or state law, an internal appeal will not be granted, but you may ask for a fair hearing.
You may ask for a fair hearing before, after or instead of asking for an internal appeal. You must file a fair hearing within 90 days of the original decision or 30 days of an appeal decision.
How Fair Hearings Work
When a Fair Hearings is requested, the first hearing will be scheduled between 7 and 30 days. Fair hearings generally take several months to resolve.
To see if you can get free legal assistance or help solving a problem, call your local Vermont Legal Aid Office or the Office of Health Care Ombudsman at 1(800) 917-7787.