What is an Appeal?

If Community Health Choice denies, limits, reduces, suspends, or stops a service, you have the right to ask us to review our decision. This is called an Appeal.

You may file an Appeal phone or by mail.

How do I file an Appeal?
You may file an Appeal by:

Phone

• Local: 713.295.2294
• Toll-free: 1.888.760.2600  or (TTY 7-1-1)

Mail
Community Health Choice, Inc.
Attention: Medical Affairs – Medical Appeals Department
4888 Loop Central Drive, Suite 600
Houston, TX 77081

Behavioral Health Appeals
Community Health Choice Texas, Inc.
Attention: Medical Affairs – Behavioral Health Appeals
P.O. Box 301411
Houston, TX 77230

If you need help completing your Appeal, Member Services can assist you by call 713.295.2294 or toll-free at 1.888.760. 2600 or (TTY 7-1-1).

Appeal Forms
If you need an Appeal Form or would like assistance completing one, please contact Member Services at 713.295.2294 or toll-free at 1.888.760.2600 or (TTY 7-1-1). A Member Services representative can provide an Appeal Form and answer any questions about the Appeals process.

How long do I have to file an Appeal?
You have 60 days from the date of the denial notice to ask for an appeal. You may request an Appeal after receiving notice of our decision.

If you want your current authorized services to continue while your Appeal is reviewed, you must request your Appeal by the later of:

• 10 calendar days after we mail the notice of action, or
• The effective date of the action.

How long will the Appeal take?
Community Health Choice will complete the standard Appeal process within:

• 30 calendar days after receiving your Appeal.

The review may be extended by up to 14 calendar days if:

• you request the extension, or
• Community Health Choice determines additional information is needed and the delay is in your best interest.

If an extension is needed, we will notify you in writing.

Emergency Appeals
If waiting for a standard Appeal could seriously jeopardize your life, health, or ability to regain maximum function, you may request an Emergency Appeal.

Emergency Appeals may be requested orally or in writing.
If approved for expedited review:

• Decision made within 72 hours after receiving all necessary information.
• Certain emergency situations receive a response within one business day.

If your request for an Emergency Appeal is denied, your Appeal will automatically be processed as a standard Appeal.

State Fair Hearing
If you disagree with the Appeal decision, you may request a State Fair Hearing.

Requests must be made within 120 days after Community Health Choice mails the Appeal decision notice.

Need Help?
A Community Health Choice Member Advocate can help you:

• File an Appeal
• Check the status of your Appeal
• Answer questions about the Appeals process
• Complete Appeals forms

Call Member Services at 713.295.2294 or toll-free at 1.888.760.2600 or (TTY 7-1-1).

For more information about the Appeals process, see page 58 of the Member handbook.