Grievances and appeals

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

• Part D drug: 7 calendar days
• Non-Part D drug: 30 calendar days
• Standard service appeal: 30 calendar days
• 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 appeal.

Part D drug appeals

You should submit the appeal form included in the denial letter with:

• Any information (documents, medical records) to support your appeal
• An Appointment of Representative form if a person other than you or your prescribing physician is appealing on your behalf

Non-Part D drug, Medicare-covered service or Medicaid-covered service appeals

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

You or your primary care provider must ask for continuation of previously approved services during the appeal process. You must make the request on or before the later of the following in order to continue your benefits:

• Within 10 days of the mailing date of our denial letter; or
• The effective date of the denial

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
Medicare Part D QIC
3750 Monroe Ave., Ste. 703
Pittsford, NY 14534-1302
Phone: 1-585-348-3300
Fax: 585-425-5301

Non-Part D drug or a standard service appeals

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. You should contact the IRE directly about your case at this stage of the process.

MAXIMUS Federal Services
3750 Monroe Ave., Ste. 703
Pittsford, NY 14534-1302
Phone: 1-585-348-3300
Fax: 585-425-5301

Note: If there is an adverse determination for a service covered by both Medicare and Medicaid, it will be sent to the IRE, and you may also ask the HHSC Appeals Department for a Fair Hearing. If the IRE and the state make different decisions, we’ll follow the decision that is most favorable to you.

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 letter tell you we were denying your appeal. Mail your request to:

MMP Clinical Department
7430 Remcon Circle
Building C, Ste. 120
El Paso, TX 79912

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. 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. However, if the HHSC Appeals Division needs to gather more information that may help you, it can take up to 14 more calendar days.