Grievances and appeals

The decision timeframe depends on the type of appeal you file.

• Standard Part D drug: 7 calendar days (benefits) or 14 calendar days (payments)
• Standard service appeal (including Non-Part D drugs): 30 calendar days or within 7 calendar days after we get your appeal for a Medicare Part B prescription drug
• Payment appeal: 60 calendar days

If your health requires it, you can ask for a fast (expedited) decision on your appeal. If you ask for a fast appeal, we will give you your answer within 72 hours after we get your expedited appeal request.

You don’t need a special appeal form. Just submit your reason in writing with:

• Any information (documents, medical records) to support your appeal
• An Appointment of Representative form if you choose to have someone else submit the appeal on your behalf

• English Appointment of Representative form
• Spanish Appointment of Representative form

• Within 10 business days after the date of our notice of action; or
• The intended effective date of the action

Part D drug appeals

When you receive our appeal decision, you can ask for an Independent Review. At this stage of the process, you should contact the Independent Review Entity (IRE) directly.

Maximus Federal Services
Part D QIC
3750 Monroe Avenue Suite 703
Pittsford, NY 14534-1302
Phone: 1-585-348-3300
Fax: 1-720-462-7575

Part C appeals (including non-Part D drugs)

If we don’t decide in your favor, your case is sent to the Independent Review Entity (IRE). We’ll send you a letter to tell you if this happens.

Note: If your problem is about a service or item that could be covered by both Medicare and Texas Medicaid, you will automatically get a Level 2 Appeal with the IRE. You can also ask for a Level 2 Appeal (known as a Fair Hearing) with the HHSC Appeals Division. If the IRE and the state make different decisions, we’ll follow the decision that is most favorable to you.
 

If your appeal involves items or services covered by Texas Medicaid or by Medicare and Texas Medicaid, you can ask for a Fair Hearing after you receive your appeal decision letter telling you we decided to uphold our initial decision. Contact Amerigroup STAR+PLUS MMP in writing. We will send your Fair Hearing request to the HHSC Appeals Division. You or your representative must ask for a Fair Hearing within 120 days of the date on the appeal decision letter telling you we were not able to change our decision. Mail your request to:

Fair Hearing Coordinator
Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan)
5959 Corporate Drive, Suite 1300
Houston, TX 77036

Or you can call Member Services at 1-855-878-1784 (TTY: 711), Monday through Friday from 8 a.m. to 8 p.m. local time. This call is free. We can help you with this request. If you need a fast decision because of your health, you should call Member Services to ask for an expedited Fair Hearing.

After your hearing request is received by the HHSC Appeals Division, you will get a packet of information letting you know the date, time, and location of the hearing. Most Fair Hearings are held by telephone. During the hearing, you or your representative can tell the hearing officer why you need the service that we denied.

The HHSC Appeals Division will give you a final decision within 90 days from the date you asked for the hearing. If you qualify for an expedited Fair Hearing, the HHSC Appeals Division must give you an answer within 72 hours.

We may be able to continue your benefits through the State Fair Hearing process if you continued to get services through the internal appeals process and you ask for continuation of benefits and a State Fair Hearing within 10 business days after the date of our notice that we upheld our initial decision to your appeal.