Cook Children's Health Plan Appeal Process
Cook Children's Health Plan maintains an internal appeal process for the resolution of medical necessity appeal requests. Cook Children's Health Plan will send a letter that informs the Member, the servicing Provider, and the ordering Provider of the Member's appeal rights, including but not limited to:
- The Process to request an internal appeal
- Expected timeframe for our response to an appeal request
- Process to obtain a free copy of the criteria used to make the decision
- How to request an Expedited (Emergency) Appeal
- Rights to External Medical Review (EMR)/Independent Review Organization (IRO)
- State Fair Hearing Process
The Member or the Member's representative may appeal an adverse benefit determination (medical necessity denial) orally or in writing. The Member may consent for a healthcare provider to act on his or her behalf as the authorized representative during the internal appeal process. Cook Children's Health PLan will send an appeal acknowledgement letter to the Member within five (5) calendar days of the appeal request.
When Cook Children's Health Plan denies or limits a covered benefit, the Member/Provider must file an Appeal request within sixty (60) days from receipt of the Notice of Adverse Benefit Determination (or ten (10) business days to ensure continuation of currently authorized services). The Member or Member's Representative must request to continue services during the appeal process.
The Standard Appeal Process will be completed within thirty (30) calendar days after receipt of the request for appeal, unless an Expedited Appeal is requested, which will be completed within seventy-two (72 hours) from the time we get the appeal request and supporting information. An expedited appeal is when Cook Children's Health Plan has to make a decision quickly based on the condition of the Member's Health, and taking time for a standard appeal could jeopardize their health or life. If the request for Expedited appeal is denied, the appeal will be resolved within thirty (30) days.
Appeals are reviewed by individuals who were not involved in the original review or decision to deny and are health care professionals with appropriate clinical expertise. Cook Children's Health Plan provides a written notice of the appeal determination to the Member and Provider. If the appeal resolution reverses the denial, Cook Children's Health Plan will promptly authorize coverage. If the appeal decision upholds the original decision to deny a service, Members will receive information regarding their right to request an External Medical Review and/or State Fair Hearing.
To learn more about appeal rights or request assistance with initiating an appeal, the Member or the Member's representative may call CCHP at 682-885-2247 or toll-free 1-800-964-2247, send email communication to CCHPDenialandappeal@cookchildrens.org or send a letter to:
Cook Children's Health Plan
Attn: Denial and Appeal Coordinator
P.O. Box 2488
Fort Worth, TX 76101-2488
State Fair Hearing/External Medical Review Process
After exhausting Cook Children's Health Plan internal appeal process, the Member has the right to request External Medical Review and/or State Fair Hearing. The request for State Fair Hearing/External Medical Review must be requested within one hundred-twenty (120) calendar days of the date that the health plan mailed the appeal decision letter or the right to request State Fair Hearing/External Medical Review is waived.
The External Medical Review (EMR) is an optional, extra step a Member may request to further review Cook Children's Health Plan's adverse benefit determination. The EMR will take place between Cook Children's Health Plan's internal appeal and the State Fair Hearing. The Member or Member's authorized representative may request one option orally or in writing:
- State Fair Hearing only
- External Medical Review and State Fair Hearing
- Emergency State Fair Hearing only*
- Emergency State Fair Hearing and Emergency External Medical Review*
*Emergency Stair Fair Hearings and Emergency External Medical Review should only be requested if the Member or Member's representative believe the Member's health will be seriously harmed by waiting for the State Fair Hearing or External Medical Review decisions.
Upon Member request, following the internal appeal, the EMR process will be conducted by a separate entity, Independent Review Organization (IRO). The IRO is contracted by HHSC to complete an independent review of the healthcare services that were denied by the health plan. The IRO will decide whether Cook Children's Health Plan's original adverse benefit determination must be reversed or affirmed.
Cook Children's Health Plan will send all documentation utilized to make it service reduction or denial decision, including information submitted by the Member, the Member's authorized representative, or the Provider during the internal appeal process to the HHSC EMR Intake Team for processing per the following timelines;
- Expedited (Emergency) EMR requests will be sent within one (1) day of receiving the EMR request, unless received after 3:00 PM CST on Friday or on a day CCHP is closed for business, the Expedited EMR request will be sent no later than noon the following business day.
- Standard EMR requests will be sent by the health plan no later than three (3) days after receiving the EMR request from the Member or the Member's Legal Authorized Representative (LAR).
The HHSC EMR Intake Team is responsible for assigning EMR requests to IROs and will monitor the EMRs for timely completion and ensure communication to Member and CCHP of IRO determination.
- IRO decision to Uphold - this means IRO agrees with the health plan's adverse determination to deny services.
- IRO decision to Partially Overturn - this means the IRO did not agree with the health plan's adverse determination entirely and will approve in part.
- IRO decision to Overturn - this means the IRO did not agree with the health plan's adverse determination and the denial has been reversed. The health plan will reinstate the services within seventy-two (72) hours of notification of the EMR decision to overturn.
Following the final EMR determination, the Member or authorized representative must decide to continue to State Fair Hearing as scheduled or formally withdraw the request for State Fair Hearing. The Member and Cook Children's Health Plan have a right to request for the IRO to attend the State Fair Hearing.
To learn more about the Member's External Medical Review/State Fair hearing process and/or request assistance, the Member or Member's Representative can contact Cook Children's Health Plan at 682-885-2247 or toll free at 1-800-964-2247, send an email to CCHPDenialandappeal@cookchildrens.org, go in person to a local HHSC office, or send a letter to:
Cook Children's Health Plan
Attn: Denial and Appeal Coordinator
P.O. Box 2488 Fort Worth, TX 76101-2488
If there are more questions about the health plan appeal process, call an HHSC Ombudsman at 1-866-566-8989 or complete the online form at www.hhs.texas.gov/managed-care-help.
