What is an appeal?
An appeal is the process you or someone acting on your behalf can request when you do not agree with the health plan's action and you want a review. This may be a denial or limited authorization of a requested service. You can find the appeals process on page 39 within the CHIP Member Handbook.
An action means the denial or limited authorization of a requested service. It includes the:
- Denial in whole or part of payment for a service.
- Denial of a type or level of service.
- Reduction, suspension, or termination of a previously authorized service.
- Failure to give services in a timely manner.
- Failure to act within regulatory timeframes.
What can I do if my doctor asks for a service or medicine for me that’s covered, but Cook Children’s Health Plan (CCHP) denies or limits it?
You may ask CCHP for another review of this decision. This is called an “appeal.” You can call Member Services and ask for an appeal.
How will I find out if services are denied?
If services are denied, we will send your provider a letter telling them why the service was denied. A copy of the letter will also be sent to you.
What are the timeframes for the appeal process?
We will send you a letter within five working days to let you know:
- That we received your request for appeal.
- If we need any more information in order to process the appeal.
We will complete the appeal no later than 30 calendar days from the date you asked for the appeal.
When do I have the right to request an appeal?
You may request an appeal whenever you do not agree with our decision to deny services or care for you. You have 60 days from the denial to request an appeal.
Does my request have to be in writing?
No. You may request an appeal by phone or in writing.
Can someone from Cook Children’s Health Plan help me file an appeal?
Yes, Member Services can help you file an appeal. They will send you an appeal request form and ask that you send it back before your appeal request is taken.
What is an Expedited Appeal?
An Expedited Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.
How do I ask for an expedited appeal?
You can ask for this type of appeal in writing or by phone. Make sure you write “I want a quick decision or an expedited appeal,” or “I feel my/my child’s health could be hurt by waiting for a standard decision.” To request a quick decision by phone, call Member Services.
Does my request for an expedited appeal have to be in writing?
We can accept your request orally or in writing.
Mail written requests to:
Cook Children’s Health Plan
PO Box 2488
Fort Worth, TX 76113-2488
What happens if Cook Children’s Health Plan denies the request for an expedited appeal?
If we deny an expedited appeal, it will be resolved within 30 days. You will get a letter telling you why and what other choices you may have.
What are the timeframes for an expedited appeal?
We have one working day from the time we get the information and appeal request.
Who can help me in filing an expedited appeal?
Member Services will help you. Call Member services at 1-800-964-2247.
INDEPENDENT REVIEW ORGANIZATION
What is an Independent Review Organization (IRO)?
An Independent Review Organization (IRO) is an outside organization that the Texas Department of Insurance (TDI) picks to review your health plan’s denial of a service you and your doctor feel is medically necessary. The IRO is not related to your doctor or your health plan.
You can ask for a review by an IRO after you complete the appeal process with us, or if we have denied a service that you think is life-threatening. There is no cost to you for this.
If the patient has a life-threatening condition the patient, or someone acting on the patient’s behalf, and the provider of record can request an immediate review by an independent review organization (IRO) and is not required to follow our internal appeal procedures.
How do I ask for a review by an Independent Review Organization (IRO)?
For a standard IRO Review, you or someone you name to act for you may file a request for external review within four months of receiving this letter. If you want to send more information to include in the review, you can send it with your request. You don’t have to pay for this review or any filing fees.
If you would like to have another person make an external review request on your behalf, both you and your authorized representative will need to complete and sign the HHS Federal External Review Process Appointment of Representative Form.
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Online: externalappeal.com (under the “Request a Review Online” heading)
If you believe your case is urgent and should be expedited, you can select “expedited” if submitting the review request online, or by emailing FERP@maximus.com, or calling Federal External Review Process at 1-888-866-6205, ext. 3326. MAXIUMS Federal Services will provide notice of the final external review decision as expeditiously as your medical conditions or circumstances require, but in no event more than 72 hours after the they receive a request for an expedited external review.
When MAXIMUS Federal Services receives your request, they will notify us, and we’ll send them all the case information for review. If you send them any more information they’ll share it with us. We may change our decision. If not, the IRO will continue the review. You’ll receive a letter with their decision for a standard request no later than 45 days after they receive the request for the external review.
If MAXIMUS Federal Services decides to overturn our decision, we will provide coverage or payment for your health care items or services.
If you have questions or concerns about your external review, call 1-888-866-6205.
You can send a complaint to us (CCHP): Members, individuals acting on behalf of
members, and health care providers may file a written or oral complaint about our utilization review process or procedures. Use the telephone numbers and address referenced above to file your oral or written complaint. We will respond to your complaint in writing within 30 days.
Complaints to TDI: A complainant also has the right to file a complaint with TDI by contacting TDI at the following address, telephone numbers, or website:
Texas Department of Insurance
PO Box 149091
Austin, TX 78714-9091
If you have any questions or need help with an appeal, please call the Care Management Department.
Member Services is available Monday - Friday from 8am-5pm at 1-800-964-2247.