How to File an Appeal

CHIP / CHIP Perinatal

What can I do if my doctor asks for a service or medicine for me that’s covered but CFHP denies or limits it?

CFHP may deny a health care service or medicine, if it is not medically necessary. A medicine can also be denied:

  • If the medicine does not work better than other medicines on the CFHP Preferred Drug List
  • If there is another medicine that is similar that you must try first that you have not used before.

If you disagree with the denial, you can ask for an appeal.


Frequently asked.

How will I find out if services are denied?

You will receive a letter telling you about the decision, with an appeal form.

When do I have the right to ask for an appeal? Does my request have to be in writing? Can someone from CFHP help me file an appeal?

If you are not happy with the decision, you can appeal by phone or by mail. Send in the appeal form, or call us. A Member Services Advocate can help you. Just call (210) 358- 6300 or toll free at 1-800-434-2347 or submit a written request at:

Community First Health Plans 12238 Silicon Drive Ste. 100 San Antonio, TX 78249 Attention: Resolution Department

What are the timeframes for the appeal process?

We will send you a letter within 5 calendar days to tell you we received your appeal. We will mail you our decision within 30 calendar days.

What if the services I need are for an emergency or I am in the hospital?

For emergencies or hospital admissions, you can request an Expedited Appeal.

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.

What are the timeframes for an expedited appeal?

If we have all the information we need, we will have an answer within one working day.

How do I ask for an expedited appeal? Who can help me in filing an appeal? Does my request have to be in writing?

Call us. Our Member Service Advocates can help you. Your request does not have to be in writing.

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

We will notify you. Your request will be moved to the regular appeal process and we will mail you our decision within 30 calendar days. If you are not happy with the reply to your appeal, you can ask for review by an Independent Review Organization.

INDEPENDENT REVIEW ORGANIZATION PROCESS

What is an Independent Review Organization?

This is a group of doctors, who are not employees of CFHP. A specialist will review your appeal and make a final decision.

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

Call us to request a review by an Independent Review Organization. You can also request it in writing.

What are the timeframes for this process?

We will mail you the final decision within 15 calendar days from when we received your request for an Independent Review Organization.

What if I am not happy with the final decision?

If you are still not happy, you can contact the Texas Department of Insurance (TDI). You can contact TDI at:

Texas Department of Insurance
P.O. Box 149104
Austin, TX 78714-9104
or 1-800-252-3439
Web:www.tdi.state.tx.us
Email:consumerprotection@tdi.state.tx.us

*Member may file a complaint through the Texas Department of Insurance at any time during this process.