II. Determination Denials and Appeals

In cases where DSAMH determines that a consumer/client does not meet eligibility criteria and denies enrollment into DSAMH's LTC system, the denial will be made by an EEU physician. The EEU will issue a denial letter to the referring organization and the consumer/client; the denial letter will include an explanation for the denial and recommendations for more effective services or additional follow-up behavioral health care service provision by the referring organization.

If the provider or the consumer/client chooses to appeal the decision, a written appeal must be filed with the DSAMH Deputy Director or designee within five (5) working days of the notification of determination. DSAMH will issue a response to an appeal within five (5) working days of receiving it. An enrollment denial upheld on appeal is subject to a second level appeal. For Medicaid enrolled consumers/clients, the second level appeal will be heard by the Division of Social Services.