Content

Appeals, Grievances, and Coverage Decisions

You have the right to request an appeal, file a grievance and ask for a coverage determination. For status or process questions or to obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call toll-free at 833.276.8306 or local at 713.295.5007 (TTY 711) October 1 through March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. You may also refer to your Evidence of Coverage for complete details.


Appeals

An appeal is a formal way of asking us to review and change a coverage decision we have made. You may file an appeal when you believe that the service, supplies, or drugs you received should be covered or that they should be covered differently than Community approved or paid them. Your doctor can also request an appeal for you.

  • CALL 833.276.8306 toll-free or local 713.295.5007 Calls to this number are free. Hours are October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system.
  • TTY
    711
    Calls to this number are free. Hours are October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system.
  • FAX
    713-295-7036
  • Write
    Appeals & Grievances
    2636 South Loop West, Suite 125
    Houston, TX 77054

Grievances

You can file a grievance when you are unhappy with your care. You can file a grievance against us or one of our network Providers, including complaints about the quality of your care. Grievances do not involve coverage or payment disputes.

  • CALL 833.276.8306 toll-free or local 713.295.5007 Calls to this number are free. Hours are October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system.
  • TTY
    711
    Calls to this number are free. Hours are October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system.
  • FAX
    713-295-7036
  • Write
    Appeals & Grievances
    2636 South Loop West, Suite 125
    Houston, TX 77054
  • Medicare Website
    You can submit a complaint about Community Health Choice (HMO D-SNP) directly to Medicare. To submit an online complaint to Medicare go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Coverage Decisions for Medical Services

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.

You may call us if you have questions about our coverage decision process.

  • CALL 833.276.8306 toll-free or local 713.295.5007 Calls to this number are free. Hours are October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system
  • TTY
    711
    Calls to this number are free. Hours are October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system.
  • FAX
    713.295.7041
  • Write
    Appeals & Grievances
    2636 South Loop West, Suite 125
    Houston, TX 77054

Determinations & Redeterminations for Prescription Drugs

A determination is a request for coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy.

To request a coverage determination, please complete an online secure form by clicking here. You can also download (this form is pending CMS approval) and submit by fax or mail.

  • FAX
    855.668.8552
  • Write
    P.O. Box 1039
    Appleton, WI 54912

If your coverage determination is denied, you may request a redeterminationPlease read this page to understand what you need to do to request an appeal. You may complete an online secure form by clicking here. You can also download (this form is pending CMS approval)  and submit by fax or mail.

  • FAX
    713.295.7041
  • Write
    Appeals & Grievances
    2636 South Loop West, Suite 125
    Houston, TX 77054

 

 

Woman and Man Looking at Laptop


H9826_IT_10045_092919_M Last updated September 30, 2019

Back To Top