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 on your denial notice to ask for an Appeal.

If you want your services to continue while your Appeal is reviewed, you must request that within 10 days of the denial notice.

How long will the Appeal take?

We will make a decision within 30 calendar days after we receive your Appeal.

If we need more information and the delay is in your best interest, we may extend the review by up to 14 calendar days. We will notify you if we need more time.

Expediated Appeals

If waiting for a standard Appeal could seriously harm your life or health, you may ask for an Expedited Appeal.

You may request an Expedited Appeal by phone or in writing.

If your request qualifies, we will:

• Make a decision within 72 hours after receiving all needed information.
• Mail the decision within three business days after the decision is made.

If your request does not qualify for an Expedited Appeal, it will be reviewed as a standard Appeal.

Independent Review Organization (IRO)

If you disagree with the Appeal decision, you may have the right to request an Independent Review Organization (IRO) review.

You must request an IRO review within 4 months after receiving the final Appeal decision.

For more information about the IRO process, see page 57 of the CHIP Member Handbook.

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 Appeal forms.

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

For more information about the Appeals process, see pages 55–58 of the CHIP Member Handbook.