An appeal is a participant’s action taken with respect to New Horizons PACE’s decision not to cover or pay for a service, including denials, reduction, or termination of services. A request to initiate, modify or continue service must first be processed as a service determination request before New Horizons PACE can process an appeal.
If you disagree with a denial or partial denial of a service determination request made by the New Horizons PACE, you may file an appeal. The service determination request is the first step of the appeals process.
If a service determination request is denied or partially denied you will receive the following: Verbal and written reasons for the denial including:
- Why the service is not necessary to maintain or improve your overall health status, considering your medical, physical, emotional and social needs.
- The results of the interdisciplinary team member's reassessment in an understandable language.
- Your right to appeal the decision under the appeals process.
New Horizons PACE provides written instructions of our appeal process. You will be given this at the time of your enrollment. You will also be given this yearly and on every occasion the interdisciplinary team denies, reduces, or suspends a service. Adaptive, interpretive, and translation services will be available to assist you if you have vision or hearing impairment or do not speak English.
If you do not speak English, a bilingual interpreter, or translation service will be available to assist you. The appeals process can be complex but remember that your New Horizons PACE interdisciplinary team is available to help.
A standard appeal is the most common type of appeal. A standard appeal is not considered to be urgent in nature. All standard appeals will be resolved as quickly as is required by the condition of your health. Standard appeals will be resolved within 30 calendar days from when we received your appeal.
An expedited appeal is used only if you believe that your life, health, or ability to regain or maintain maximum function will be seriously at risk by waiting 30 calendar days for the decision.
If your request for an expedited appeal does not rise to this level, it will be considered a standard appeal. Expedited appeals are resolved as quickly as your health condition requires, but no later than 72 hours after receipt.
New Horizons PACE may extend the time up to 14 calendar days if we can show that additional time is needed to the State of Missouri (MO HealthNet) in order for us to collect information and it is in your best interest to take the additional time. You can also request us to extend the time.
You will receive verbal and written notification of the denial or partial denial of service determination request from a New Horizons PACE interdisciplinary team member, you may request an appeal at that time by telling a staff member, telephoning the PACE Center at 314-897-7223 or by writing a letter and mailing/faxing it to:
New Horizons PACE
Director of Quality and Compliance
5035 Manchester Ave.
St. Louis, MO 63110
New Horizons PACE will respond to your request for an appeal as quickly as possible. You or your designated representative will be notified of our decision to approve or deny the appeal as quickly as your condition requires. For a standard appeal- no later than 30 calendar days. For an Expedited appeal no later than 72 hours of the decision. New Horizons PACE’s starts the appeal s process when appeal is received.
You have the right to file an appeal if New Horizons PACE:
- Denies or partially denies your service determination request or enrollment.
You or your designated representative can file a standard or expedited appeal verbally or in writing. We suggest requesting an Appeal Submission Form from New Horizons PACE staff. You may also file an appeal in a letter. If you need assistance putting your appeal in writing, please ask for help from one of your interdisciplinary team members.
When a standard appeal has been filed, New Horizons PACE will work with you and do our best to address your concerns with a solution that satisfies all parties involved.
The appeals process includes:
A reasonable opportunity for you to present evidence related to the disputed service, in person, as well as in writing.
A review of an appeal by an appropriate third-party reviewer or committee. An appropriate third-party reviewer or member of a review committee must be a person who meets the following:
- Have specialized certification (credentialing) in the field related to the appeal.
- Was not involved in the original service determination request process.
- Does not have a stake in the outcome of the appeal.
All appeals and documentation related to the appeal remains confidential.
Appeals can be either in your favor (approved, upheld, agreed to) or not in your favor (denied, not in agreement). Notice of any favorable decision must explain the conditions of the approval in an understandable language. If we decide in your favor on a standard appeal, we will provide or arrange for services as quickly as your health condition requires, but in no later than thirty (30) calendar days from your initial request for an appeal.
If New Horizons PACE decides in your favor on an expedited appeal, we will give permission for you to get the service or provide the service as quickly as your health condition requires, but no later than 72 hours from your initial request for an appeal.
If New Horizons PACE does not decide in your favor on a standard or expedited appeal, you have a right to file an external appeal. New Horizons PACE will notify you, the Centers for Medicare and Medicaid Services (CMS), and MO HealthNet in writing of the denial or partial denial of the appeal. Notice of the partially or fully adverse decision must:
- State the specific reason(s) for the denial.
- State the specific reason(s) why the service would not improve or maintain the participant’s overall health status.
- Inform the participant of his or her right to appeal the decision; and
- Describe the external appeal rights listed below including the Medicare Appeal and Medicaid Appeal process
If you receive Medicaid, New Horizons PACE will continue to furnish the disputed services until the decision if the final determination of the appeal is made if the following conditions are met:
- New Horizons PACE must continue to furnish to the participant all other required services.
- New Horizons PACE is proposing to terminate or reduce services currently being furnished to you.
- You request the continuation of the services being furnished by New Horizons PACE and that you may be liable for the costs of the disputed services if the appeal decision is not in your favor.
Additional Appeal Rights
New Horizons PACE will help you or your designated representative to file an appeal for Medicare or Medicaid. The process you choose depends upon whether you are eligible for Medicaid only, Medicare and Medicaid (dually eligible), Medicare only or pay privately for New Horizons PACE’s services. If you are enrolled in Medicaid only and are appealing a Denial of Enrollment or an Involuntary Disenrollment, you can appeal at any time during the appeals process by contacting:
MO HealthNet Division Attn: Participant Appeals
615 Howerton Court, 2nd Floor
Jefferson City, MO 65109
If you are enrolled in Medicare only, you may appeal using Medicare’s external appeal process as described in Option 1 below.
If you are enrolled in Medicaid and Medicare, we will help you choose which appeals process you should follow as you can choose only one process. If you are enrolled in Medicaid ONLY you can appeal at any time during the appeals process using the State’s Fair Hearing Process.
If you are not sure which program(s) you are eligible for, you may call New Horizons PACE at (833) 654 -7223 for assistance.
If you are currently enrolled in New Horizons PACE and enrolled in both Medicare and Medicaid or Medicare only, you may choose to appeal using Medicare’s external appeals process.
The federal Medicare program contracts with an Independent Review Entity (IRE) to provide external review on appeals involving PACE programs. This review organization is completely independent of New Horizons PACE. We will send your case file to Medicare's IRE for you within 60 calendar days from the date of the decision by the third-party reviewer.
The IRE will conduct the review as expeditiously as your health condition requires:
- 72 hours or up to 17 calendar days in certain cases, for an expedited review.
- 30 to 44 calendar days for healthcare you are waiting for.
- 30 to 60 calendar days for payment of a denied bill.
If the IRE disagrees with New Horizons PACE (over turns the denial), the IRE will send you a letter and a letter to New Horizons PACE telling New Horizons PACE to pay for or provide for services requested in the appeal.
If the IRE agrees with New Horizons PACE’s original decision (upholds the denial of the appeal) the IRE will send you a letter to tell you what you can do.
NEW HORIZONS PACE operates as your MO HealthNet Medicaid benefit provider under the Missouri Department of Social Services. If you would like a further appeal after a negative decision of a New Horizons PACE appeal, you may have the right to a hearing with the Division of Legal Services.
The hearing may be your only opportunity to present evidence and show why you believe the wrong decision was made. The Hearings Unit can only use the evidence provided during the hearing in their decision. The Hearings Unit cannot discuss the facts of your case before or after the hearing.
Please click here (hyper link to https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1696.pdf) to fill out the CMS Appointment Representative Form. By clinking this link, you are acknowledging that you are leaving the New Horizons PACE website.
5035 Manchester Ave.
St. Louis, MO 63110
Hours: M - F | 8am - 4:30pm
Site currently under review by CMS
Last updated September 8, 2022