最新糖心Vlog

CHIP & CHIP Perinate Member Complaints & Appeals

If you have a problem with your medical care or services, you have a right to file a complaint. A complaint can be filed when you are unhappy with your care. Some examples are:

  • The care you get from your doctor
  • The time it takes to get an appointment or be seen by a doctor
  • The doctors you can choose for care

An appeal is a request for your managed care organization to review a denial or a grievance again.

You have the right to ask for an appeal if you are not happy or disagree with an adverse benefit determination. An adverse benefit determination means the denial or limited authorization of a requested service. It includes:

  • 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

Complaint Process

You can submit a complaint online through our Member Portal.

PCHP Member Advocate can help you file a complaint. Call 1-800-814-2342 (TTY English 7-1-1) to have a Member Advocate write down your complaint, or you can mail a written complaint to:

最新糖心Vlog Community Health Plan
Attention: Member Advocate
P. O. Box 560347
Dallas, TX 75356

Be sure to include the following:

  • Member's first and last name
  • ID number (on the front of the Member ID card)
  • Member's address and telephone number
  • Explanation of the problem

What are the requirements and timeframes for filing a complaint?

The member or provider can file a complaint at any time. The complaint can be oral or in writing. If the complaint is oral, a complaint form will be sent to the member for a signature.

An acknowledgment letter will be sent to the member within 5 business days after we receive the complaint. A resolution to a complaint will be no longer than 30 calendar days.

If I am not satisfied with the outcome, who else can I contact?

If you are not happy, you can ask for an appeal of a complaint resolution by calling us at 1-800-814-2342 or writing to:

最新糖心Vlog Community Health Plan
Attention: Member Advocate
P.O. Box 560347
Dallas, TX 75356-9005

Do I have a right to meet with a complaint appeal panel?

Within 5 business days of getting your request for an appeal of a complaint, the Member Advocate will send you a letter to let you know that your complaint appeal came to us.

The Complaint Appeal Panel will look over the information you sent us and discuss your case. It is not a court of law. You have the right to appear in front of the Complaint Appeal Panel at a specific place to talk about the written complaint appeal you sent to us. When we make the decision on your appeal, we will send you a response in writing within 30 calendar days after we receive your appeal.

Need more help?

If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance (TDI) by calling toll-free 1-800-252-3439. If you would like to make your request online or in writing, .

Appeal Process

You can submit an appeal online through our Member Portal.

最新糖心Vlog CHIP's Member Advocate can help you file an appeal. Call 1-800-814-2342 (TTY English 7-1-1) to have a Member Advocate write down your appeal, or you can mail a written appeal to:

最新糖心Vlog Community Health Plan
Attention: Member Advocate
P.O. Box 560347
Dallas, TX 75356

There are three types of appeals:

  1. Standard Appeal: An appeal that does not involve urgent care such as emergency care, life-threatening conditions, or continued hospitalization.
  2. Expedited Appeal: An expedited appeal is available for denial of emergency care, a denial of continued hospitalization, and denial of another service if the requesting healthcare provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient.
  3. Specialty Appeal: The provider of record may request a specialty appeal, which requests that a specific type of specialty provider review the case.

How will I find out if services are denied?

If your service or claim is denied, you will get a letter from 最新糖心Vlog Community Health Plan telling you about this decision. It will tell you about your right to appeal. You can also read about these rights in your Member Handbook.

What are the timeframes for the appeal process?

Our deadlines to resolve an appeal and send a written decision to the member or someone acting on the member鈥檚 behalf and the provider of record are:

  • Standard Appeal: 30 calendar days of receipt of the appeal.
  • Expedited Appeal: The earlier of 1 working day from the date all information necessary to complete the appeal is received or 72 hours after we receive the appeal request.
  • Retrospective (Claim) Appeal: 30 calendar days after receipt of appeal. However, we may extend this deadline once for a period not to exceed 15 calendar days.
  • Specialty Appeal: The provider must request this type of appeal within 10 working days from the date the appeal was requested or denied. We will complete the specialty appeal and send our written decision to the member or person acting on the member鈥檚 behalf and the provider within 15 working days of receipt of the request for the specialty appeal.

We will send an appeal acknowledgment letter to the appealing party within 5 working days from receipt of the appeal. If we need more information to help us make a decision, we will include a list of what is needed.

Does my request have to be in writing?

Your request does not have to be in writing. You can ask for an expedited appeal by calling the Member Advocate.

What happens if PCHP denies the request for an expedited appeal?

If you ask for an expedited appeal that does not involve an emergency, an ongoing hospitalization, or services that are already being provided, you will be told that the appeal cannot be rushed. We will continue to work on the appeal within the standard timeframe and respond to you within 30 days from the time the appeal was received.

Independent Review Organization

If you have completed our appeal process and do not agree with the appeal decision, you or someone acting on your behalf (including your healthcare provider) has the right to ask for an external review. The external review process is a review by an Independent Review Organization (IRO), which is MAXIMUS Federal Services.

MAXIMUS Federal Services does not have any affiliation with 最新糖心Vlog Community Health Plan or its doctors. We will not have any involvement with the external review or the decision. We will also accept the external review decision.

Deadline to File an External Review

You must ask for an external review by MAXIMUS Federal Services within 4 months. This is from the date you received our notice to uphold an appeal decision. If you do not ask for it within this time frame, you may lose your right to an external review.

Standard and Expedited External Reviews

  • Standard External Review: This is a standard review by the IRO. A standard external review does not need an urgent review or decision right away by the IRO (MAXIMUS Federal Services).
  • Expedited External Review: This is an urgent review and requires a decision right away by the IRO. Usually, an expedited review by 最新糖心Vlog Community Health Plan must be completed before you qualify for an expedited external review. An expedited external review may be requested when:
    • You or your representative have asked for an expedited appeal and want an expedited external review at the same time; and the timeframe for an expedited appeal would place the member's life, health, or ability to regain maximum function in danger; or
    • The member has completed an appeal with 最新糖心Vlog Community Health Plan and the decision was not in the member鈥檚 favor, and:
      • The timeframe to do a standard external review (45 days) would place the member's life, health, or ability to regain maximum function in danger;
      • The decision is about an admission, care availability, continued stay, or emergency healthcare services where the member has not been discharged from the facility.

In urgent care situations, the IRO will accept a request for an external review from a medical professional who knows about the member鈥檚 condition. The medical professional will not be required to submit proof of authorization.

Filing an External Review

Complete, sign, and return the HHS-Administered Federal External Review Request Form to MAXIMUS Federal Services to request an external review. Please note that a release of medical information to MAXIMUS Federal Services is included as part of the request form. It must be signed by the member or the member鈥檚 legal guardian. Mail or fax the form along with the adverse benefit determination notice you received directly to:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Phone: 1-888-866-6205 (toll-free)
Fax: 1-888-866-6190
Email: ferp@maximus.com

You can also submit your external review request online at  under the 鈥淩equest a Review Online鈥� link in the heading. If you have any questions or concerns before or during the external review process, you can call MAXIMUS at the above number. You can submit additional written comments to the external reviewer at the MAXIMUS mailing address above. If any additional information is submitted, it will be shared with 最新糖心Vlog Community Health Plan to give us an opportunity to reconsider the denial.

Timeframe to Resolve

  • Standard External Review: MAXIMUS will provide a decision as soon as possible, but no later than 45 calendar days after receiving the request.
  • Expedited External Review: MAXIMUS will provide a decision as quickly as medical circumstances require, but no later than 72 hours after receiving the request.