ABA Appeal Template.pdf

I am filing an appeal for my Medicaid-eligible child, (name and Medicaid number XX). My child was diagnosed with autism spectrum disorder (ASD) by a licensed professional and prescribed applied behavior analysis (ABA) therapy. Since that time, I have been unable to locate a provider. The EPSDT federal mandate covers early, periodic, screening, diagnosis, and treatment and applies and requires the state Medicaid agency to cover and ensure my child receives this medically necessary care. Prompt treatment is essential and every day without treatment threatens current and future functioning. We are requesting and are entitled to a qualified ABA provider since it has been XX days/months/years since we were prescribed ABA. We want an ABA provider to be made immediately available to us. - Family Contact Information XX (Name, Address, Phone, Email, Child name and Medicaid number)
Contact Information for managed care plans: If no email is listed, consider faxing your appeal.
Aetna Better Health of IL - Email: [email protected], Tel: 866-329-4701, Fax: 877-668-2076, Mail: Aetna Better Health of IL, Attn: Appeals Dept., P.O. Box 81139, Cleveland, OH 44181. Formerly Illinicare Health.
Blue Cross Blue Shield Community Plan – Email: unknown, Tel: 877-860-2837, Fax: 866-643-7069, Mail: BCBS, Attn: Grievance and Appeals Unit, P.O. Box 27838, Albuquerque, NM 87125-9705.
CountyCare (HealthChoice) Health Plan – Email: unknown, Tel: 312-864-8200, Fax: 866-200-5031, Mail: CountyCare Health Plan, Attn: CCH A&G Department, P.O. Box 21153, Eagan, MN 55121. Cook County only.
Humana Health Plan – Email: unknown, Tel: 1-800-787-3311, Fax: 1-855-336-6220, Mail: Attn: Grievance and Appeal Dept., PO Box 14546, Lexington, KY 40512-4546
Meridian Health Plan – Email: unknown, Tel: 866-606-3700, Fax: 312-508-7255, Mail: Meridian Health, Attn: Grievance Coordinator or Appeals, Coordinator, PO box 44287, Detroit, MI 48226.
Molina Healthcare of Illinois - Email: [email protected], Tel: 855-687-7861, Fax: 855-502-5128, Mail: Molina of Illinois, Attn: Grievance and Appeals Dept., 1520 Kensington Road Suite 212, Oak Brook, IL 60523.
Youthcare –Contact the case worker with the Illinois Department of Child and Family Services. edicaid Only – A Medicaid member not enrolled in managed care can file an appeal at [email protected].