You can file an appeal if your doctor asks for a service for you but
CHRISTUS Health Plan denies it, reduces it, terminates it or fails to
provide or make payments (in whole or in part) for a benefit. You can ask
that the decision is looked at again by another qualified medical
professional. The appeal will be reviewed by someone who did not make the
original decision and does not report to the person who made the original
decision. All requests for an appeal must be made within 180 calendar days
from the date on the initial denial letter. You can send any comments,
documents or other data to help with your appeal.
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Fast (Urgent) Appeal:
You, a person acting on your behalf, or your provider may ask for a
fast (expedited) appeal if you, a person acting on your behalf, or your
provider believe that you have a life-threatening condition. We will
also expedite your appeal if you are currently in the hospital or we
have denied your emergency care. You can ask by phone if you need a
fast appeal.Call us at 1-844-282-0380 to file a fast appeal. If you are
appealing because you have an ongoing emergency, or denial of continued
hospitalization or prescription drug, we will process your appeal and
give you an answer within 24 hours. For all other fast appeals, we will
process your appeal and give you an answer no later than 72 hours from
the day we get your fast appeal request.
Note:
If you have an urgent medical need or received a denial for continued
hospitalization,you have the right to request an urgent external review by
MAXIMUS Federal Services at the same time as the internal appeal.
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Standard Appeals
: There are 2 types of standard appeals: Pre-Service, or Prior
Authorization, and Post-Service, or Claim.
For standard pre-service(prior authorization) appeal, we
will send you an acknowledgement letter within 5 working days from receipt
of the appeal. We will resolve the appeal and send a written decision to
you or someone acting on your behalf and the provider of record within 30
calendar days of receipt of the appeal.
For standard post-service (claim) appeal, we will send
you an acknowledgement letter within 5 working days from receipt of the
appeal. We will resolve the appeal and send a written decision to you or
someone acting on your behalf and the provider of record within 60 calendar
days of receipt of the appeal.
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Specialty Appeal
: A specialty appeal is available after the denial of an initial
appeal. The provider of record mayrequest this type of
appeal in writing within 10 working days from the denial and must show
good cause for the specialty appeal. We will complete the specialty
appeal and send our decision in writing within 15 working days of
receipt of the request for the specialty appeal.
In addition to appeals, you can file two types of grievances for health
insurance exchange plans:
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Adverse Determination Grievance:
You or your representative(s) may submit an adverse determination
grievance if the health plan has denied pre-authorization
(certification) for a proposed procedure, has denied full or partial
payment for a procedure that you have already received, or is denying
or reducing further payment for an ongoing procedure that you are
already receiving and that has been previously covered. The health plan
will notify you before terminating or reducing coverage for an
ongoing course of treatment, and will continue to cover the treatment
during the appeal process.
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Administrative Grievance:
You or your representative(s) may submit an administrative grievance if
you object to how the health plan handles other matters, such as its
administrative practices that affect the availability, delivery, or
quality of health care services; claims payment, handling or
reimbursement for health care services; or if your coverage has been
terminated.
You or your representative
must notify the health plan that you wish to request a grievance within
180 days after receiving the initial decision.