Community First Health Plans - EOC: General Information

A. MEMBER COMPLAINT/APPEAL PROCESSESS

General. Members are required to submit all Complaints through Community First’s internal Complaints and Appeal process, which we have outlined for You below.

Community First encourages the informal resolution of Complaints. Community First will not retaliate against You or a Contract Holder, including cancellation of coverage or refusal to renew coverage, simply because the Contract Holder, You, or person acting on behalf of the Contract Holder or You, has filed a Complaint against Community First, or Appealed a decision of Community First.

Community First will not retaliate against any Participating Physician or Provider, including termination of or refusal to renew a contract, simply because a Participating Physician or Provider has, on Your behalf filed a Complaint against Community First or Appealed a decision of Community First. At any time, You have the right to contact the Texas Department of Insurance at 1-800-252-3439 or in writing at P. O. Box 149104, Austin, Texas 78714-9104.

Where to File a Complaint. Complaints/Appeals should be directed to Community First's Member Services Department at 1-877-698-7032 or 210-358-6262 or in writing to: 12238 Silicon Drive, Suite 100, San Antonio, Texas 78249.

Process for Complaint Resolution.
Complaints will be handled in the following manner:

Step	Action

1.	You, or someone acting on Your behalf, notifies Community First orally, or in writing, of a Complaint.

2.	If Community First receives a written Complaint, we will send You a letter acknowledging receipt of Your Complaint within five (5) Working Days of receipt of the Complaint. This letter will include the date Community First received the Complaint, as well as a description of the Complaint and Appeals process and timeframes. If Community First receives an oral Complaint, we will include a one-page Complaint form, along with the above information, which should be returned immediately for prompt resolution of the Complaint.

3.	Community First will investigate the Complaint and send You or Your designated representative a letter explaining the resolution of Your Complaint. Community First will acknowledge, investigate and resolve Your Complaint within thirty (30) calendar days from the date we receive Your written Complaint, or Your completed Complaint form.

4.	Investigation and resolution of Complaints relating to Emergency Care, or denials of continued Hospital stays shall be concluded in accordance with the medical or dental immediacy of the case, but will not exceed one (1) Working Day from the date the Complaint is received by Community First.

Member Appeals Process.
Appeals will be handled in the following manner:

Step	Action

1.	If You are not satisfied with Community First's resolution of Your Complaint, You or Your designated representative may notify Community First orally, or in writing, of Your wish to Appeal our decision.

2.	Community First will send You a letter acknowledging receipt of Your Appeal within five (5) Working Days of receiving your written request for Appeal.

3.	Community First will schedule a hearing before an Appeals Panel where You or Your Dependent normally receive health care services within the Service Area, unless You and Community First agree to another site. In lieu of appearing in person, You may address a written Appeal to the Appeals Panel. The Appeals Panel will consist of individuals appointed by Community First. The Panel consists of equal numbers of Community First staff, Physicians or other Providers; and Members. No individual serving on the Panel may have previously been involved in the disputed decision that is the subject of the Appeal. All Physicians or other Providers serving on the Panel must have experience in the area of care that is in dispute and must be independent of the Physician(s) or Provider(s) who made any prior determination(s). If specialty care is in dispute, the Appeals Panel will include an additional person who is a specialist in the field of care to which the Appeal relates. Members serving on the Appeals Panel may not be employees of Community First.

4.	No later than five (5) Working Days before the hearing, unless You agree otherwise, Community First shall provide You or Your designated representative:
	any documentation that Community First staff will present to the Panel; the specialization of any Physicians or Providers consulted during the investigation; and the name and affiliation of each Community First representative on the Panel.

	You, or Your designated representative if You are a minor or disabled, are entitled to:
	Appear in person before the Appeals Panel; Present alternative expert testimony; and Request the presence of and question any person responsible for making the decision resulting in the Appeal.
	Relevant documents will be reviewed by the Appeals Panel and considered along with relevant presentations and discussions. You or Your designated representative and Community First will be allowed to present any relevant information and have witnesses or counsel present.

5.	The Appeals Panel renders a recommendation and Community First notifies You or Your designated representative of Community First's decision regarding Your Appeal.

6.	Community First will complete the Appeals process no later than thirty (30) calendar days after the date Your request for an Appeal is received by Community First. Any review by an Appeals Panel will be obtained within this timeframe.

7.	At any time, You have the right to contact the Texas Department of Insurance at 1-800-252-3439.

Arbitration. If after completion of the process described above, You remain dissatisfied, You may exercise Your right to submit the matter to Arbitration which is final and binding. All claims, disputes, controversies and other matters in question related to any of the terms of this Certificate of Group Health Coverage shall be arbitrated and the arbitration proceeding will be conducted pursuant to the Texas Arbitration Act.

Notice of the demand for arbitration shall be made in writing and filed with Community First subject to this provision and the demand shall be made within a reasonable time not to exceed thirty (30) days after the process described in Sections 3 through 5 above has been exhausted.

The award rendered by the arbitrators shall be final and binding on You and Community First and judgment may be entered upon it in accordance with applicable law in any federal or Texas Court having jurisdiction.

Maintenance of Records. Community First will maintain a record of each Complaint and/or Appeal as well as any proceedings and any actions taken on a Complaint and/or Appeal for three (3) years from the date of receipt of a Complaint. You may obtain a copy of the record on Your Complaint, Appeal and any proceedings.

Process for Appealing an Adverse Determination.
Adverse Determination is the determination by Community first, or its Utilization Review Agent, that the health care services furnished or proposed to be furnished to a Member are not Medically Necessary or not appropriate.

A Complainant (You, an authorized representative, a provider of record acting on your behalf) may appeal an Adverse Determination orally, or in writing. Appeals of Adverse Determinations will be handled in the following manner:

Step	Action

1.	Within five (5) Working Days from receipt of the Appeal, Community First will send the appealing party a letter acknowledging the date of Community First's receipt of the Appeal. This letter will include a reasonable list of documents needed to be submitted to Community First for the Appeal.

2.	When Community First receives an oral Appeal of an adverse determination, Community First will send the appealing party a one-page Appeal form.

3.	Emergency care denials, denials for care of life-threatening conditions and denials of continued stays for hospital patients may follow an expedited Appeal procedure, if requested. This procedure will include a review by a health care provider who has not previously reviewed the case, and who is of the same or a similar specialty as typically manages the medical condition, procedure, or treatment under review. The time frame in which such an expedited Appeal must be completed will be based on the medical or dental immediacy of the condition, procedure, or treatment, but will not exceed one (1) Working Day following the date that the Appeal, including all information necessary to complete the Appeal, is made to Community First.

4.	Adverse Determination standard Appeals will include a review by a health care Provider who has not previously reviewed the case and who is not a subordinate of the initial reviewer. Community First will notify You, Your designated representative and Your provider of record of the outcome of the Appeal of the Adverse Determination, explaining the resolution of the Appeal. Community First will provide written notification to the appealing party as soon as practical, but no later than 30 days after we receive the oral or written Appeal.

5.	An appropriate health care provider will make all Appeal decisions for adverse determination. If the Appeal is denied, and within ten (10) Working Days the health care provider sets forth, in writing, good cause for having a particular type of a specialty Provider review the case, the denial will be reviewed by a health care provider in the same or similar specialty as typically manages the medical, dental, or specialty condition, procedure, or treatment under discussion for review. Such specialty review will be completed within fifteen (15) Working Days of receipt of the request.

Process for Requesting Independent Review of an Adverse Determination

You, Your designated representative and Your provider of record will be notified at the time of the denial of the Appeal of an Adverse Determination of Your right to have Your Appeal reviewed by an Independent Review Organization (IRO). You may only seek independent review in the case of an Adverse Determination.
Community First will provide to You, Your designated representative and Your provider of record with the prescribed form. The form must be completed and returned to Community First including the medical release section signed by You or the Members legal guardian in order to begin the Independent Review process.
In a circumstance involving a Life-Threatening Condition, You are entitled to an immediate Appeal to an Independent Review Organization and are not required to comply with the procedures for an Adverse Determination Appeal to Community First. In these circumstances, You, Your designated representative, or Your provider of record may contact Community First by telephone to request the review and provide the required information.
There is no right of Appeal of the IRO determination by You, Your designated representative, Your provider of record or Community First. This Appeals process does not prohibit You from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or relief available under law, if the requirement of exhausting the Appeal process places Your health in serious jeopardy.

B. IDENTIFICATION CARDS

Any identification cards (called ID Cards) issued by Community First, in connection with the Group Health Care Coverage are for identification only and remain the property of Community First. Possession of an ID Card does not convey any rights to benefits under the Group Health Care Coverage. Any person who receives services, supplies, or other benefits to which the person is not entitled by the terms of the Group Health Care Coverage and of the Group Contract will be charged for the actual costs incurred by Community First for any such services or supplies or for the amount of any such benefits. If any Member permits another person to use the Member's ID Card, Community First may:

invalidate that Member's ID Card; and
terminate that Member's Coverage as provided in the "WHEN YOUR COVERAGE ENDS" section.

C. CONFIDENTIAL NATURE OF MEDICAL RECORDS

Any information from a Member's medical records or received from Providers or Hospitals incident to the physician-patient or Hospital-patient relationships will be kept confidential. Such information may not be disclosed without the consent of the Member, except as is reasonably necessary in connection with the administration of the Group Health Care Coverage, as permitted by law. Each Member agrees that Participating Providers or Consulting Physicians may release medical records to Community First, and any of its subsidiaries or affiliates, as is reasonably necessary for claim determination, litigation, or other normal business activities.

D. ASSIGNMENTS

Benefits provided to a Member under the Group Health Care Coverage are personal to the Member and are not assignable or otherwise transferable.

E. RELATION AMONG PARTIES AFFECTED BY THE CONTRACT

The relationship between Community First and any Hospital is that of an independent contractor. No Hospital is an agent or employee of Community First, nor is Community First, or any employee of Community First, an employee or agent of any Hospital. Each Hospital will maintain the Hospital-patient relationship with Members under the Contract and is solely responsible to Members for Hospital supplies and services.

The relationship between Community First and any Participating Physician or other Participating Provider is that of an independent contractor. No Participating Physician or other Participating Provider is an agent or employee of Community First, nor is Community First, or any employee of Community First, an employee or agent of a Participating Physician or other Participating Provider. Each Participating Physician or other Participating Provider will maintain the provider-patient relationship with Members under the Group Contract and is solely responsible to Members for supplies and services furnished to Members.

Neither the Contract Holder nor any Member under the Group Contract is the agent or representative of Community First. Any Member under the Group Contract will not be liable for any acts or omissions of Community First, its agents or employees, or of any Hospital, Physician, or other health care provider with which Community First, its agents or employees make arrangements for furnishing supplies and services to Members.

A Member may, for personal reasons, refuse to accept procedures or courses of treatment recommended by Participating Physicians. Participating Physicians will use their best efforts to render all needed, appropriate professional services in a manner compatible with the Member's wishes. Each Participating Physician will do this to the extent it is consistent with the Physician's judgment as to the needs of the person and proper medical practice. If a Member refuses to follow a recommended treatment or procedure and the Participating Physician believes that there is no professionally acceptable alternative, the Member will be so advised.

If the Member then still refuses to follow the recommended treatment or procedure:

the Member will be given no further treatment for the condition being treated; and
neither Participating Providers, Hospitals, nor Community First, will have any further responsibility to provide care for that condition.

However, if the Member later accepts the recommended treatment, it will
be provided. If the refusal of recommended treatment continues and such
refusal results in an unsatisfactory relationship (as described in the
“Termination of Members for Cause” part of the “WHEN YOUR
COVERAGE ENDS” section of the Certificate of Group Health Care
Coverage), Community First may give written notice to the Member that
the person is no longer a Member for the Group Health Care Coverage.
The procedures for receiving and resolving complaints described above
are available to Members.

F. NOTICES AND OTHER INFORMATION

Any notices, documents, or other information under the Group Contract may be sent by United States Mail, postage prepaid, addressed as follows:

If to Community First: At its address shown on the first page of this Certificate.
If to a Member: To the last address provided by the Member on an enrollment or change of address form actually delivered to Community First.

G. WHEN YOUR COVERAGE ENDS

Employee and Dependent Coverage.

Your Employee Coverage or Your Dependent Coverage will end when the first of these occurs:

(1)	Your membership in the Covered Classes for the Coverage ends because Your employment ends (see "End of Employment" section below).

(2)	The Group Contract ends.

(3)	You fail to pay, when due, any contribution required for the Coverage. But failure to contribute for Dependent Coverage will not cause Your Employee Coverage to end.

(4)	You no longer reside, live or work within the Service Area.

(5)	You become eligible under Part A of Medicare by reason of reaching age 65 and You elect Medicare as Your primary benefit program (for active Eligible Employees and their Qualified Dependents).

(6)	The coverage is Dependent Coverage and Your Employee Coverage ends.

Your Dependent Coverage for a Qualified Dependent will end when that person:


(1)	Moves his or her permanent residence outside the Service Area. Excluded from this requirement are dependent unmarried children whose eligibility for coverage is determined by a court-ordered child support or medical support document.

(2)	Ceases to be a Qualified Dependent. (See the section entitled "Continued Coverage for an Incapacitated Child" below.)

End of Employment: For purposes of Coverage under the Group Contract, Your employment ends when You are no longer considered to be employed by the Employer. But, for Coverage purposes, the Contract Holder may consider You as still employed and in the Covered Classes during certain types of absences from work. The Contract Holder decides whether You are to be considered as still employed during those types of absences and for how long. In making such a determination, the Contract Holder must not discriminate among persons in like situations.

You may be considered as still employed up to any time limit on Your type of absence. When so considered, Your Eligible Employee Coverage and Dependent Coverage will be continued only while You are paying contributions for such coverage at the time and in the amounts, if any, required by the Contract Holder (whether or not those Coverages would otherwise be Non-contributory Coverages). But the Coverages will not be continued after they would end for a reason other than end of employment. The types of absences and the time limits are those set forth below:

Cancellation and Non-Renewal of Coverage: ERS determines Your eligibility.

H. CONTINUATION PRIVILEGE

Continued Coverage for an Incapacitated Child: Your Dependent Coverage for a child will not end on the date the age limit under the Employer's Health Benefits Plan or in the definition of Qualified Dependent is reached if both a. and b. below are true:

The child is then mentally or physically incapable of earning a living. The Group Contract Holder must receive proof of this within the next thirty-one (31) days; and
The child otherwise meets the definition of Qualified Dependent.

If these two conditions are met, the age limit will not cause the child to stop being a Qualified Dependent under the Coverage. This will apply as long as the child remains incapacitated and dependent unless coverage is otherwise terminated with the terms of the Group Contract.

Continued Coverage at You or Your Dependent’s Option: You or Your Dependent may be eligible for continued coverage upon the occurrence of certain events as described below.

Continued Coverage under COBRA. A Member may be eligible to continue coverage under the Consolidated Omnibus Reconciliation Act of 1985 (COBRA) with the same benefits as provided under the Group Contract upon the occurrence of a qualifying event. Qualifying events are listed below, along with the length of time that COBRA coverage is available.

YOUR BENEFITS

DEPENDENTS BENEFITS

Qualifying Event	Length of Time COBRA Coverage is Available
Termination of Your Employment (unless due to gross misconduct)	18 months (29 months for a person who qualifies for Social Security disability benefits)

Reduction in Your work hours	18 months (29 months for a person who qualifies for Social Security disability benefits)

You become entitled to Medicare	36 months

Your death	36 months

Your divorce or legal separation	36 months

Dependent child loses eligibility	36 months

The continuation of coverage periods shown above include any periods that the Member was covered under any other continuation of coverage. The continuation of coverage may be terminated sooner than the indicated length of time when:

- the plan ends;

- the Member fails to timely pay the premium;

- the Member first becomes eligible for Medicare;

- in the case of a Member who is disabled when the continuation coverage begins, the Member becomes ineligible for disability benefits under the Social Security Act; provided, however, this will apply only if the Member becomes ineligible after such continuation coverage has been in effect for at least eighteen (18) months; or

- the Member becomes covered under another group health plan that does not contain any exclusion or limitation with respect to any such pre-existing condition of the Member.

Election for continuation of coverage under COBRA must be made within sixty (60) days of the later of: (i) the occurrence of a qualifying event, or (ii) the date You or Your Dependent receives the appropriate COBRA election forms that must be provided by the Employer or Contract Holder.

b. Continued Coverage under State Law. A Member may be eligible to continue benefits under the provisions of Texas Insurance Code, Section 1271.301. A Member is entitled to continued coverage under the requirements set forth below if their coverage under the Group Contract has been terminated for any reason, except involuntary termination for cause, or if they have completed continuation of coverage as provided under COBRA. The Member must have been continuously insured under the Group Contract for at least three (3) consecutive months immediately prior to termination.

(1) If the Member has completed continuation of coverage as provided under COBRA, such continuation, under State Law, must be offered to the Member not less than thirty (30) days prior to the expiration of COBRA;

(2) Such coverage continuation must be requested within thirty-one (31) days following the later of (a) the date the group coverage would otherwise terminate, or (b) the date the Member is given notice of the right of continuation by the Employer or Group Contract Holder;

(3) The Member must pay the Employer or Contract Holder on a monthly basis, in advance, the amount of contribution required by the Contract Holder or Employer plus two percent (2%) of the group rate for the coverage being continued on the due date of each payment;

(4) The Member's written election of continuation, together with the first contribution must be paid within 31 days following the later of (a) the date the Group Health Care Coverage would otherwise terminate, or (b) the date the Member is given notice of the right of continuation by the Employer or the Group Contract Holder;

(5) Continuation may not terminate until the earliest of (a) six (6) months after the date the election is made; (b) the date on which failure to make timely payments would terminate coverage; (c) the date on which the Member is covered for similar services and benefits by another health plan; or (d) the date on which group coverage terminates in its entirety;

(6) Not less than thirty (30) days before the end of the six (6) months after the date the Member elects continued coverage, the Group Contract Holder will notify the Member that the Member may be eligible for coverage under the Texas Health Insurance Risk Pool and the Group Contract Holder will provide the address for applying to the pool to such Member.

c.
Continued Coverage for Dependents. A Dependent may be eligible for continued coverage if the Dependent's previous eligibility for coverage hereunder ceases because of the severance of the family relationship or the retirement or death of the employee; and the family member or the Dependent has been a member of the group for a period of at least one year or is an infant under one year of age. A Member electing such continued coverage must pay premiums for the coverage directly to the Contract Holder. The Member will have the option of paying the premiums in monthly installments. The premium for continuation of coverage shall be no more than the premium charged under the Group Contract for the Member had the family relationship not been severed.

An Eligible Employee must give written notice to the Contract Holder within fifteen (15) days of any severance of the family relationship that might activate the continuation coverage option under this Section and, upon receiving this notice, the Contract Holder shall immediately give written notice to each affected Dependent of the continuation option; however, such written notice may be given by the Eligible Employee's Dependent. On receipt of notice of the death or retirement of an Eligible Employee, the Contract Holder will immediately give written notice the Eligible Employee's Dependents of the coverage continuation option. Within sixty (60) days from the date of the severance of the family relationship or the retirement or death of the Eligible Employee, the Dependent must give written notice to the Contract Holder of the desire to continue coverage.
Coverage under the policy will remain in effect during the sixty (60) day period if policy premiums are paid. Such continued coverage shall continue until: (1) the Member fails to make a premium payment in the time required to make that payment; (2) the Member becomes eligible for substantially similar coverage under another health benefit plan; or (3) a period of three years has elapsed since the severance of the family relationship or the retirement or death of the Eligible Employee.