Complaints and Appeals

Appeals

STAR, STAR+PLUS, and STAR Kids members

Sometimes, we make decisions about care and services you or your provider asks for. When we decide to deny or reduce a service, you may ask for an appeal. During an appeal, a doctor or other qualified reviewer not involved in the original decision, looks again at your case. He or she will review all the information about your appeal and make an appeal decision.

How to request an internal appeal

You must ask for an appeal within 60 calendar days of the date on the decision letter. You can also ask your provider or another person to appeal for you.

You can appeal in several ways:

• Send a letter or a Medicaid appeal request English / Spanish form by mail or fax to:

  Amerigroup Appeals
  P.O. Box 62429
  Virginia Beach, VA 23466-2429
  Fax: 877-881-1305

• Call Member Services at 800-600-4441 (TTY 711).
  STAR Kids members, call 844-756-4600 (TTY 711). Tell us you want to file an appeal.

After you request an appeal

We’ll send you a letter with our appeal decision within 30 calendar days of getting your request.

If your appeal involves services we previously approved and are now reducing or ending, you may be able to keep getting those services while your appeal is being reviewed. To do so, you must file the appeal before the later of the two dates below:

• Ten calendar days after the date we send you the denial notice, or
• The day our letter says your service will end or be reduced

If we uphold our decision to deny or reduce services, you may have to pay for any services you kept getting during the appeal.

Call Member Services at 800-600-4441 (TTY 711) for status updates on your appeal or questions about the appeal process. STAR Kids members, call 844-756-4600 (TTY 711).

Learn more about the appeal process, including emergency appeals for emergency or life-threatening situations, by reading the member handbook.

How to request an External Medical Review and State Fair Hearing

If you disagree with our internal appeal decision, you have the right to ask for an External Medical Review from and Independent Review Organization and a State Fair Hearing from the Texas Health and Human Services Commission (HHSC). There are no fees to you for these reviews. You must request an External Medical Review and State Fair Hearing within 120 calendar days of the date on our appeal decision letter. If you don’t get an appeal decision within the required time frame, you can ask for an External Medical Review and State Fair Hearing without getting our appeal decision.

You can ask for an emergency External Medical Review and State Fair Hearing due to an emergency or life-threatening situation, but you must complete our internal appeal process.

You can ask for an External Medical Review and State Fair Hearing by:

• Calling Member Services at 800-600-4441 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711).
• Mailing or faxing a letter or a State fair hearing and external medical request  English / Spanish  form to:

  Amerigroup Fair Hearing Coordinator
  PO Box 62429
  Virginia Beach, VA 23466-2429
  Fax: 855-883-9039

If you ask for an External Medical Review and State Fair Hearing within 10 days from the date we sent the appeal decision letter, you may be able to keep getting the service or benefit we denied or reduced if you kept getting it during the internal appeal process, at least until the final hearing decision is made. If the State Fair Hearing upholds our decision to deny or reduce services, you may have to pay for any services you kept getting.

If you ask for a State Fair Hearing, we’ll send you a packet of information telling you the date, time, and location of the hearing. Most State Fair Hearings are held by telephone, so you won’t need to attend in person. HHSC will give you a final decision within 90 calendar days from the date you asked for the hearing. If you have any questions during the process, please call Member Services at 1-800-600-4441 (TTY 711). STAR Kids members, call 1-844-756-4600 (TTY 711).

You can ask for a State Fair Hearing without an External Medical Review. The request process is the same as described above for requesting both. An External Medical Review cannot be requested without a State Fair Hearing, but you can withdraw your request for the hearing after you get the External Medical Review decision.

Call Member Services at 800-600-4441 (TTY 711) for status updates on your External Medical Review or State Fair Hearing or questions about the process. STAR Kids members, call 844-756-4600 (TTY 711).

Your decision to ask for an internal appeal or State Fair Hearing with our without an External Medical Review won't affect your ability to access quality care.

CHIP and CHIP Perinate members

If we tell you we won’t pay for all or part of the care your doctor recommended, you can appeal. An appeal is when you ask us to look again at the care we said we won’t pay for.

How to request an appeal

You must submit your appeal within 60 days of the date on our first denial letter. You can also ask your doctor or another person to appeal for you.

You can appeal in 2 ways:

• Call Member Services at 1-800-600-4441 (TTY 711)

• Send a letter or a  Medical Appeal Form to:

Amerigroup Appeals
2505 N. Highway 360, Suite 300
Grand Prairie, TX 75050

After you request an appeal

We’ll send you a letter with the answer to your appeal. We’ll do this within 30 calendar days from the time we get your appeal except for urgent appeals and certain other types of appeals that need a quicker decision.

If you aren’t happy with our decision, the provider can send us a letter to ask for a second level appeal/specialty review. This letter must be sent within 10 business days from the date on our letter with the answer to your first level appeal.

You can ask for an independent external review after either your first appeal or a second level specialty review.

How to request an independent external review

If we still won’t pay for care after a first level appeal or a specialty review, and the decision involved medical judgment, you can ask for an external review by an independent third party. Our decision letter and the member handbook tell you how to ask for this kind of review. One way is to send an HHS-Administered Federal External Review Request Form in English or Spanish. Complete and sign the form. Then, send it to the address on the form.

Your decision to file an appeal or ask for an independent review won’t affect your ability to get quality health care.

To learn more about the appeal process, expedited appeals, second level specialty reviews, and independent external reviews, read the member handbook.

Visit Member Resources to read the CHIP member handbooks.