Download a paper Grievance and Appeal Request form.

Fill it out and or mail it to:

CHRISTUS Health Plan
Attn: Appeal and Grievance Dept.
PO Box 169009
Irving, TX 75016

Or fax it to 1-866-416-2840

Appeals must be made in writing, but grievances can also be made over the phone by calling
1-844-282-0380 (711 for TTY users).

Appeals

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.

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.

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.

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.

Grievances

In addition to appeals, you can file two types of grievances for health insurance exchange plans:

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.

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.

If you are not satisfied with the answer to your appeal or grievance, you can also contact the Texas Department of Insurance (TDI), the New Mexico Managed Health Care Bureau (MCHB) at the Office of the Superintendent of Insurance (OSI) or the Louisiana Department of Insurance (LDI), for Texas, New Mexico and Louisiana members, respectively.

Texas Department of Insurance
Consumer Protection
PO Box 149091
Austin, Texas 78714 - 9091

Phone:  1-800-252-3439
Email:  ConsumerProtection@tdi.texas.gov

Office of Superintendent of Insurance - MHCB
P.O. Box 168
1120 Paseo de Peralta
Santa Fe, NM 87504 - 1689

Phone:  1-505-827-4601 or toll free 1-855-427-5674
Fax:  505-827-4734, Attn: MHCB
Email:  mhcb.grievance@state.nm.us

Louisiana Department of Insurance
P.O. Box 94214
Baton Rouge, LA 70804 - 9214

Phone:  1-800-259-5300
Website:  https://www.ldi.la.gov/onlineservices/ConsumerComplaintForm

Download a paper Grievance and Appeal Request form.

Fill it out and fax it to 1-866-416-2840 or mail it to:

CHRISTUS Health Plan
Attn: Appeal and Grievance Dept.
PO Box 169009
Irving, TX 75016

Grievances and expedited appeals can be made over the phone by calling 1-844-282-0380 (711 for TTY users).

If filing an expedited appeal or grievance, make sure to ask your physician or supplier for any information to support your case. If mailing your request or submitting online, please include “expedited or fast appeal or “expedited grievance” on the form.

If you disagree with a coverage or payment decision, you can file an appeal. You have 60 calendar days from the date of the denial notice to file a standard appeal. We can extend the timeframe if the member shows good cause.

For Medicare Parts C and D, you can file an appeal when:

• You get a denial for expedited (time-sensitive) Part C coverage
• You get a denial for expedited (time-sensitive) Part D prescription drug coverage
• When you disagree with what the plan pays or what you must pay out-of-pocket for your medical or prescription services
• When you are refused service by your plan, doctor or hospital
• When the plan reduces or stops your medical benefit
• When the plan reduces or stops your prescription benefit
• When you receive a denial on any type of request
• When you want to ask us to cover a drug that is not on our drug list or to request coverage rule exception

If you have a complaint or are dissatisfied with the way a health plan, prescription drug plan or delegated entity provides health care services, you can file a grievance.

For example:

• You are dissatisfied with a change in premiums or cost-sharing arrangements from one year to the next
• You have difficulty getting through on the phone to speak to a CHRISTUS Health Plan representative
• You experience poor quality of services from a provider
• You experience unsatisfactory interpersonal aspects of care such as rudeness
• You express general dissatisfaction about a copayment, coinsurance or deductible amount

Members, appointed representatives (a friend, advocate, guardian or health care proxy), legal representatives of a member’s estate and providers can file an appeal for Medicare Part C or Part D Drug Coverage.

An Appointment of Representative (AOR) form or other equivalent notice is required when someone files an appeal on behalf of a member. Both the member and the representative (including attorneys) must complete, sign and date it. An AOR form is not required for expedited and pre-service appeals that are requested by the member’s physician or provider.

• Appointment of Representative Form - English (PDF)
• Appointment of Representative Form - Spanish (PDF)
• LP Appointment of Representative Form - CMS 1696 English (PDF)
• LP Appointment of Representative Form - CMS 1696 Spanish (PDF)

Instead of an Appointment of Representative form, members can also provide equivalent written notice. This notice must include:

• Name, address and telephone number of the member
• Medicare Beneficiary Identifier (MBI) 
• Name, address and telephone number of the individual being appointed
• A statement that the member is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative
• Signature and date by the member making the appointment and the person being appointed
• A statement saying that the individual accepts the appointment

An expedited or fast appeal can be filed when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in serious jeopardy.

Expedited appeals may not be requested for cases that only involve a claim for payment for services already received. However, if a case includes both a payment denial and a pre-service denial, you have a right to request an expedited appeal for the pre-service denial.

An Appointment of Representative form is not required for expedited and pre-service appeals that are requested by the member’s physician or provider.

Members can request an expedited grievance when:

• CHRISTUS Health Plan determines that a Part C reconsideration/appeal request can’t be expedited
• CHRISTUS Health Plan determines that a Part D reconsideration/appeal request can’t be expedited, and the drug has not yet been received by the member
• The Health Plan is extending the expedited appeal or organizational determination timeframe
• The Health Plan refused to expedited an organizational determination or reconsideration or invoked an extension to organizational determination or reconsideration timeframe

For Part C redetermination (appeals), a standard appeal decision is issued within 60 calendar days after receiving the request. A standard pre-service appeal will be completed within 30 calendar days from receipt. If CHRISTUS Health Plan upheld or partially overturned the appeal request, it will submit a written explanation with complete case file to the independent review entity (MAXIMUS Federal Services) contracted by CMS no later than:

• 30 calendar days from the date received for standard pre-service appeals
• 60 calendar days from the date received for standard post-service reconsideration appeals

For Part D coverage redetermination (appeals), a standard appeal decision is issued within seven (7) calendar days after receiving the request. Learn more about Part D Coverage Determinations.

Part D redetermination (appeals) may be submitted to the following addresses:
 
Part D Prescription Drug Benefit and DMP At-Risk Appeals: 
C2C Innovative Solutions, Inc. 
Part D Drug Reconsiderations 
P.O. Box 44166 
Jacksonville, FL 32231 - 4166 
 
Late Enrollment Penalty Appeals
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
P.O. Box 44165
Jacksonville, FL 32231 - 4165
 
For Mail Sent by Couriers Such as Fedex and UPS: 
C2C Innovative Solutions, Inc. 
Part D QIC 
301 W. Bay St., Suite 600 
Jacksonville, FL 32202
 
Customer Service Telephone Numbers: 
Appellants (Toll-Free) – (833) 919-0198
Plans – (904) 394-4700
 
Plan Fax Numbers: 
Expedited Appeals – (904) 539-4093
Standard Appeals – (904) 539-4097 
LEP Appeals – (904) 539-4072 
Auto-Forwarded Appeals – (904) 539-4099 
Effectuation Notice (Drug & LEP) – (904) 539-4101 
 
Appellant Fax Numbers (Toll-Free):
Expedited Appeals – (833) 710-0579
Standard Appeals – (833) 710-0580
LEP Appeals – (833) 946-1912

C2C Website: 
https://PartDAppeals.C2Cinc.com 
 
C2C Part D QIC Plan Liaison Email Address: 
MedicarePartDAppeals@c2cinc.com

For expedited appeals, the plan will issue a decision as quickly as possible and no later than 72 hours after receiving the request.

CHRISTUS Health Plan will respond to standard grievances within 30 days from the grievance receipt. For expedited grievances, we will respond within 24 hours of receipt.

CHRISTUS Health Plan is required to provide information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with the health plan.

Members or their representatives can contact CHRISTUS Health Plan Generations Appeal and Grievance Department at 1-844-282-0380 (711 for TTY users) to request a list of the aggregate number of grievances, appeals, and exceptions filed with the health plan.

Written request can be sent to:

CHRISTUS Health Plan Generations
Attn: Appeal and Grievance Department
P.O. Box 169009
Irving, Texas 75016
Fax: 1-866-416-2840

Download and fill out the Appeals & Grievances Form and mail it to:

CHRISTUS Health Plan
Attn: Appeal and Grievance Dept.
PO Box 169009
Irving, TX 75016

Or fax it to 1-866-416-2840

The table below lists the turnaround time for US Family Health Plan appeals and grievance submissions.