What is an appeal?
An appeal is the process you or someone acting on your behalf can ask for when you do not agree with Cook Children’s Health Plan’s action and you want a review.
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 the Customer Care Department and ask to speak to a Member Advocate. They will help you.
When do I have a right to ask for an appeal? Does my request have to be in writing?
You have the right to ask for an appeal within 60 calendar days after you receive the letter telling you that the service was denied. You can ask for an appeal orally or in writing.
Any oral request for appeal must be confirmed by a written signed appeal by you or your representative unless an expedited appeal is requested. You can appeal the denial of payment as a whole or in part.
If you are currently receiving authorized services and would like to keep getting them while the appeal is pending you must ask for an appeal no later than 10 business days after Cook Children’s Health Plan (CCHP):
- mailed of the notice of the action; or
- the intended effective date of the proposed action adverse benefit determination
You can also get an extension if CCHP shows that there is need for more information and if the delay is in the member’s interest. If CCHP needs to extend benefits, you will get a written notice of the reason for the delay.
How will I find out if services are denied?
If your services are denied, you and your doctor will get a letter that tells you the reason for denial. The letter will tell you how to file an appeal and how to ask for a State Fair Hearing.
What are the timeframes for the appeal process?
Cook Children’s Health Plan (CCHP) has up to 30 calendar days to decide if your request for care is medically needed and covered. We will send you a letter of our decision within 30 days. In some cases you have the right to a decision within one business day.
You can get a quick decision if your health or ability to function could be seriously hurt by waiting. The resolution of your appeal can be extended up to fourteen (14) calendar days of the appeal if you ask for more time, or if CCHP can show that we need more information. We can only do this if more time will help you. We will send you a letter telling you why we asked for more time.
Can someone from Cook Children's Health Plan help me file an appeal?
Yes. Member Advocates are available to help you file an appeal. Once they help you file it, they will send you a letter and ask you or someone acting on your behalf to sign a form and send it back to CCHP.
If you disagree with CCHP’s decision on the appeal, you have the right to ask for a State Fair Hearing. You can ask for a State Fair Hearing at any time after the health plan’s Appeals process has been completed.
If you disagree with Cook Children's Health Plan's decision on the appeal, you have the right to ask for a state fair hearing. You can ask for a state fair hearing at any time during or after the health plan's appeals process.
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 may 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 your Service Coordinator or a Member Advocate at 1-844-843-0004.
Does my request for an expedited appeal have to be in writing?
We can accept your request orally or in writing. You can send requests to:
Cook Children's Health Plan
P.O. Box 2488
Fort Worth, TX 76113-2488
Who can help me file an expedited appeal?
You can ask for an expedited appeal if you feel that serious medical problems will occur. Our Medical Director will review your request within one business day. You will be told, by phone and in a letter, of the decision. If you need help filing an appeal, please call 1-844-843-0004.
What happens if Cook Children's Health Plan (CCHP) denies the request for an expedited appeal?
If CCHP denies an expedited appeal, the appeal is processed through the normal appeal process, which will be resolved within 30 days. You will receive a letter explaining why and what other choices you may have.
What are the timeframes for an expedited appeal?
CCHP must decide this type of appeal in one working day from the time we get the information and request.
Can I ask for a state fair hearing?
If you, as a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative.
If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 120 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 120 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at:
Cook Children's Health Plan
Attn: Member Services
P. O. Box 2488
Fort Worth, TX 76113-2488 or call 1-800-964-2247.
You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made if you ask for a fair hearing by the later of: (1) 10 calendar business days following Cook Children’s Health Plan’s mailing of the notice of the action adverse benefit determination.
If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.
For questions about your complaint or appeal or to get the status of your complaint or appeal, please call Member Services at 1-800-964-2247.