You, someone acting on your behalf or your provider of record can ask CHRISTUS Health Plan to make an exception to our coverage rules.
There are several types of exceptions that you, someone acting on your behalf or your provider of record can ask us to make.
- Cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- Ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
You, someone acting on your behalf or your provider of record call:
CHRISTUS Health Member Services at 1-844-282-3025
Express Script at 1-800-935-6103
Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
The Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. The adjudication timeframes do not begin until your prescriber submits his or her supporting statement to the Plan for review.
If CHRISTUS Health Plan’s coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.
You, someone acting on your behalf or your provider of record has the right to appeal an unfavorable determination (denial) orally or in writing. A physician who has not previously reviewed the case will make the appeal decision. The appealing party must send the appeal, whether orally or in writing, no later than 180 days after the date of receiving written notification of the unfavorable determination.
To submit an oral appeal, call the following toll-free number: 1-844-282-0380
To submit a written appeal, mail or fax the written appeal to the following address or fax number:
Appeals and Grievances Department
PO BOX 169009
IRVING, TX 75016
Our deadlines to resolve the appeal and send a written decision to the enrollee or someone acting on the enrollee’s behalf and the provider of record are:
Expedited Appeal: One working day from the date we receive all information necessary to complete the appeal.
Standard Appeal: 30 calendar days of receipt of the appeal.
We may provide the determination by telephone or electronic transmission, but will provide a written determination within three working days of the initial telephonic or electronic notification.
If an appeal is requested and we continue to deny the request, we will send you a written decision and automatically send your case to an independent reviewer.
Independent Review Organization (External Review)
MAXIMUS Federal Services will perform an expedited review for life-threatening (urgent care) services and issue a decision within 72 hours of the request that the determination be made.
An expedited external review happens faster if a person asks for it by calling toll-free telephone number: 1-888-866-6205
The 72-hour timeframe for an expedited request begins when the phone call ends.
A person may also ask for an expedited external review by mail or fax to:
MAXIMUS Federal Service
3750 Monroe Avenue, Suite 705
Pittsford, NY 1453
You may submit a standard external review request via mail, fax, or submit an online request for an external review within four months after the date you received the final denial notice from CHRISTUS Health Plan.
MAXIMUS Federal Services will perform a standard review and issue a written notice of the final external review decision as soon as possible, but no later than 45 days after receipt of the request.
Mail or fax your request directly to CHRISTUS Health Plan or send your request to:
MAXIMUS Federal Service 3750
Monroe Avenue, Suite 705
Pittsford, NY 1453
For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.