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CHIP Appeals

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.

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:

  1. That we received your request for appeal.
  2. If we need any more information in order to process the appeal.
  3. If you called us to request an appeal, you will receive a letter that tells you send a signed request in writing back to Cook Children’s Health Plan.

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.

Does my request have to be in writing?

Yes. Any oral request for appeal must be confirmed by a written signed appeal by you or your representative.

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 (or download now) and ask that you send it back before your appeal request is taken. Call Member services at 1-800-964-2247.

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. Call Member services at 1-800-964-2247.

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
Attn: Appeals
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.

How do I ask for a review by an Independent Review Organization (IRO)?

Call Care Management. We will send you a letter if we deny a service because it is not medically necessary. The letter will include a form you can fill out to ask for an IRO.

What are the timeframes for this process?

If it is not a life-threatening condition, no later than the earlier of the:

  1. 15th day after the date the IRO gets all the information they need to make their decision; or
  2. 20th day after the date the IRO gets the request for a review.

If it is a life-threatening condition, no later than the earlier of the:

  1. 5th day after the date the IRO gets all the information they need to make their decision; or
  2. 8th day after the date the IRO gets the request for a review.

 

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.