What can I do if my doctor asks for a service or medicine for me that’s covered but Community First Health Plans denies it or limits it?
Community First might 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 Community First 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.
How will I find out if services are denied?
You will receive a letter telling you about this. You will also get an appeal form.
When does a Member have the right to ask for an appeal?
You can appeal if you are not happy with the decision. You may also ask for an appeal if Community First denied payment of services in whole or part. Just call: STAR Medicaid: 1-800-434-2347 STAR Kids: 1-855-607-7827 or send us a written appeal request:
Community First Health Plans
12238 Silicon Drive Ste.100
San Antonio, TX 78249
Attention: Resolution Department
We will send you an appeal form to fill out and send back to Community First.
Can someone from Community First help me file an appeal?
Yes, we can help you file an appeal. If you call to request an appeal, we will send you an appeal form to fill out and send back to Community First. We must receive a signed, written appeal form from you to begin processing your appeal, unless you are requesting an expedited appeal.
What are the timeframes for the appeal process?
A letter will be mailed to you within 5 days to tell you we received your appeal. We will mail you our decision within 30 days. You have the right to ask for an extension up to 14 days. If Community First needs more information, we might ask for an extension. If we need an extension, we will tell you in writing. We will tell you the reason for the delay and how this will help you. You have the right to keep getting any current medical services Community First already approved while we process your appeal if you file your appeal on or before:
- 10 days from the date you received our decision letter or
- The date our decision letter says your medical services will be reduced or end.
What if I am not happy with the answer to my appeal? Can I request a State Fair hearing?
Call us to ask for a State Fair Hearing. You can ask for a State Fair Hearing at any time. It can be during or after Community First’s appeal process.