Appeals, Complaints, Fair Hearings, and Grievances

 

Appeals, Complaints, Fair Hearings, and Grievances

The Agency of Human Services offers several ways to address dissatisfaction with our programs and resulting coverage and/or eligibility decisions.

• An appeal is a request to review a recent decision that denied, terminated, or reduced services. These are usually resolved within 45 days.

• An expedited appeal may be requested in situations where an individual or an individual's doctor believes that the time required for a regular appeal could seriously risk the individual's life or health.

• A complaint addresses a general process or program or personnel. There is no formal response back to the individual.

• A fair hearing is a legal meeting where an impartial hearing officer reviews the decision. Fair hearings are scheduled within 30 days of a request. 

• A grievance addresses an issue or incident within the last 60 days that is not about covered services, authorized services or eligibility. A response is usually provided within 90 days.

 

How to File an Appeal or Fair Hearing

If you think Vermont Health Connect has made a mistake, you can appeal its decision. To appeal means to tell Vermont Health Connect that you think the action is wrong, and ask for a fair review of the action. There are multiple ways to start an appeal:

Login to your online account and click on “My Requests;”

• Call Vermont Health Connect toll-free at 1-855-899-9600;

• Send a letter letting us know what you wish to appeal:

           Vermont Health Connect
           280 State Dr.
           Waterbury, VT  05671

• File a fair hearing request directly with the Human Service Board.

When you file an appeal, you can choose to be represented in the process by someone other than yourself. Eligibility and other important information will be explained to you when you call Vermont Health Connect.
 

How to File a Complaint or Grievance

There are three ways to file a complaint or grievance:

Login to your online account and click on “My Requests;”
• Call Vermont Health Connect toll-free at 1-855-899-9600;

• Send a letter to:

           Vermont Health Connect
            280 State Dr.
           
Waterbury, VT  05671

 

Timely Eligibility Determination

Vermont Health Connect must make a decision on your application no later than 30 days after your application date unless delay is caused by an unexpected emergency or administrative problem beyond the Department's control, or yours. If you do not get a decision within 30 days, you may call Vermont Health Connect at 1-855-899-9600 for more information or to request a fair hearing.

 

Communication Regarding Case Resolution

Staff at Vermont Health Connect’s Customer Support Center are permitted to work on member cases up until the point that a formal grievance or appeal is filed. If a mistake was made, they will work to correct it.  If, on the other hand, the system worked properly and procedures were followed, then the customer support representative may not be able to take further action. If a member disagrees with state or federal laws or policies, then policymakers – not operational staff – are positioned to take action.

If a member files a formal grievance or appeal, only staff in the Department of Vermont Health Access (DVHA) Fair Hearings Unit are permitted to discuss the case with a member. Customer Support Center staff, and staff in other units of DVHA, are required to tell the member that they can’t discuss the case and direct them to the Fair Hearing Unit.

If the case is referred from the Fair Hearings Unit to the Human Services Board (HSB), only the Assistant Attorney General (AAG) will communicate directly with the member – although staff from the Fair Hearings Unit will testify at the HSB hearing.