Due Process Local Appeal Request Form

Local Appeal Request Form: Use this form to appeal a decision to deny, reduce, suspend, or terminate services.


OPTIONAL: If you would like to provide additional supportive documentation, please use the following email: dueprocess@oaklandchn.org or contact Customer Service at the temporary phone number: 1-888-847-0513. Whether you are requesting a fast or standard appeal, there is limited time available to present additional evidence in the case of an expedited (fast) appeal resolution.

Identify your relationship to the person receiving services.

Person receiving services
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Complete only if you are a guardian or representative of the person receiving services.

Notice to Legal Representatives

If you are the legal representative, you will be required to submit written verification to file this appeal on the individual’s behalf.

What agency is providing the services you are appealing?

What action did the agency take?

Found in the box labeled "Action" on the Due Process letter

Found in box labeled "Effective Date" on the Due Process letter

Found in the box labeled "Service" on the Due Process Letter

(Reminder if we are terminating, suspending or reducing a previously authorized service–your appeal must be filed timely, within 60 calendar days from the date of the notice. You must also file the request within 10 calendar days from the date of the notice or before the intended effective date the service is stopped or reduced, whichever is later, and the authorization for the service must not have expired.)

Select or enter value
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Expedited- If the standard resolution could seriously jeopardize your physical or mental health, and if approved, you will be notified in 2 days, and the appeal decision will be completed within 72 hours. Standard- The appeal decision will be made within 30 calendar days.

Standard
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NOTICE TO REFERRING PRACTITIONERS ONLY

Oakland Community Health Network (OCHN) provides your treating practitioner with the opportunity to discuss any Utilization Management (UM) medical necessity denial decision with a physician or appropriate behavior healthcare reviewer by contacting Customer Service at the temporary phone number: 1-888-847-0513.

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