Prior Authorization Appeal & Resubmission

A member may request an expedited (emergency) medical appeal verbally or in writing in cases where time expended in the standard resolution could jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function. An expedited (emergency) medical appeal concerns a decision or action by PCHP that relates to:

• Health care services including, but not limited to, procedures or treatments for a member with an ongoing course of treatments ordered by a health care provider, the denial of which, in the provider’s opinion, could significantly increase the risk to a member’s health or life
• A treatment referral, service, procedure, or other health care service that if denied could significantly increase risk to a member’s health or life

After PCHP gets the member’s letter or call and agrees their request for an appeal should be expedited, we will send them a letter with the answer to their appeal. We will do this within 72 hours from receipt of the appeal request.

If the member’s appeal is about an ongoing emergency or hospital stay, we will call them with our decision within 1 business day from the receipt of their appeal request. We will also send them a letter with the answer to their appeal within 3 business days.

If we do not agree that the member’s request for an appeal should be expedited, we will call them right away. We will send them a letter within 2 calendar days to let them know how the decision was made and that their appeal will be reviewed through the standard review process.

The member or the member’s LAR has the option of requesting a state fair hearing and an external medical review at the same time. The member must ask for the state fair hearing and external medical review within 120 days of the date on the PCHP letter that tells of the decision being challenged.

Or the member or member’s LAR has the option of requesting only a State Fair Hearing no later than 120 days of the date of the PCHP appeal decision notice. At any time during or after the PCHP appeals process.

If a member, as a member of the health plan, disagrees with the health plan’s decision, the member has the right to ask for a state fair hearing.

The member may name someone to them by contacting the health plan and giving the name of the person the member wants to represent him or her. A provider may be the member’s representative if the provider is named as the member’s authorized representative.

The member or the member’s representative must ask for the state fair hearing within 120 days of the date on the health plan’s letter that tells of the decision being challenged. If the member does not ask for the state fair hearing within 120 days, the member may lose his or her right to a state fair hearing. To ask for a state fair hearing, the member or the member’s representative should send a letter to the health plan at:

• Parkland Community Health Plan
  ATTN: State Fair Hearing
  P.O. Box 560347 Dallas, TX 75356

OR

• Call: 1-888-672-2277

If the member asks for a state fair hearing within 10 days from the time the member gets the hearing notice from the health plan, the member has the right to keep getting any service the health plan denied, based on previously authorized services, at least until the final hearing decision is made. If the member does not request a state fair hearing within 10 days from the time the member gets the hearing notice, the service the health plan denied will be stopped.

If the member asks for a state fair hearing, the member will get a packet of information letting the member know the date, time, and location of the hearing. Most state fair hearings are held by telephone. At that time, the member or the member’s representative can tell why the member needs the service the health plan denied.

HHSC will give the member a final decision within 90 days from the date the member asked for the hearing.

If a member, as a member of the health plan, disagrees with the health plan’s internal appeal decision, the member has the right to ask for an external medical review. An external medical review is an optional, extra step the member can take to get the case reviewed for free before the state fair hearing. The member may name someone to represent him or her by writing a letter to the health plan telling the MCO the name of the person the member wants to represent him or her. A provider may be the member’s representative. The member or the member’s representative must ask for the external medical review within 120 days of the date the health plan mails the letter with the internal appeal decision. If the member does not ask for the external medical review within 120 days, the member may lose his or her right to an external medical review. To ask for an external medical review, the member or the member’s representative should either:

Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to the Member Notice of MCO Internal Appeal Decision letter and mail or fax it to PCHP by using the address or fax number at the top of the form;

• Call PCHP at 1-888-672-2277.
• Email PCHP at PCHPComplaintsandAppeals@phhs.org

If the member asks for an external medical review within 10 days from the time the health plan mails the appeal decision, the member has the right to keep getting any service the health plan denied, based on previously authorized services, at least until the final state fair hearing decision is made. If the member does not request an external medical review within 10 days from the time the member gets the appeal decision from the health plan, the service the health plan denied will be stopped.

The member, the member’s authorized representative, or the member’s LAR may withdraw the member’s request for an external medical review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing the member’s external medical review request. The member, the member’s authorized representative, or the member’s LAR must submit the request to withdraw the EMR using one of the following methods: (1) in writing, via United States mail, email, or fax; or (2) orally, by phone or in person. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an external medical review during member appeal processes related to adverse benefit determinations based on functional necessity or medical necessity. An external medical review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.

Once the external medical review decision is received, the member has the right to withdraw the state fair hearing request. The member may withdraw a state fair hearing request orally or in writing by contacting the hearings officer listed on Form 4803, Notice of Hearing.

If the member continues with a state fair hearing and the state fair hearing decision is different from the Independent Review Organization decision, the state fair hearing decision is final. The state fair hearing decision can only uphold or increase member benefits from the Independent Review Organization decision.

If a member believes that waiting for a standard external medical review will seriously jeopardize the member’s life or health, or the member’s ability to attain, maintain, or regain maximum function, the member or member’s representative may ask for an emergency external medical review and emergency state fair hearing by writing or calling PCHP. To qualify for an emergency external medical review and emergency state fair hearing the member must first complete PCHP’s internal appeals process.

If the child has a life-threatening condition or we deny prescription drugs or intravenous infusions that are already being received, the member, someone acting on their behalf, or the provider can ask for an immediate review by an Independent Review Organization. The member does not have to go through the PCHP internal appeal process first.

An Independent Review Organization (IRO) is an organization that has no connection to us or the doctors that were previously involved in your treatment or decisions made by us about services that have not been given.

Maximus Federal Services, Inc. is the Independent Review Organization that will conduct an external review when requested.

A member can ask for an IRO review by filling out the “Request for a Review by an Independent Review Organization” form that is sent with the decision letter. Complete, sign, and return the HHS-Administered Federal External Review Request Form to MAXIMUS Federal Services to request an external review.

Please note that a release of medical information to MAXIMUS Federal Services is included as part of the request form. It must be signed by the member or the member’s legal guardian.

Mail or fax the form along with the Adverse Determination notice received directly to:

• MAXIMUS Federal Services
  3750 Monroe Avenue, Suite 705
  Pittsford, NY 14534

• Phone: 1-888-866-6205 (toll-free)
• Fax: 1-888-866-6190

The member can also submit the external review request online at externalappeal.cms.gov under the “Request a Review Online” link in the heading. If the member has any questions or concerns before or during the external review process, they can call MAXIMUS at the above number. The member can submit additional written comments to the external reviewer at the MAXIMUS mailing address above. If any additional information is submitted, it will be shared with Parkland Community Health Plan to give us an opportunity to reconsider the denial.