Claim Appeals 

A claim appeal is a written request by a provider to give further consideration to a claim reimbursement decision based on the original and or additionally submitted information. The document submitted by the provider must include verbiage including the word "appeal." All claim appeals must be filed within 120 days of date of the Explanation of Payment (EOP).  

View our  Level I and II Claim Appeal Request Process and Form. 
 
An appeal must meet the following requirements: 

  • Claim Appeals are to be submitted individually for each claim number.
  • Submit one copy of the Remit/EOB for each claim appealed. 
  • Circle the individual claim being appealed on the individual remit/EOB.
  • Indicate if this is a Level I or II Claim Appeal
  • If applicable, indicate the incorrect information and provide the corrected information that should be used to appeal the claim. 
  • Attach a copy of any supporting documentation that is required or has been requested by Parkland Community Health Plan. Supporting documentation to prove timely filing should be the acceptance report from Parkland Community Health Plan to the provider’s claims clearinghouse. Supporting documentation must be on a separate page and not copied on the opposite side of the Remit/EOB. 

Please submit your appeals and all supporting documentation via: 

  1. Online: Save time and submit your appeal online through our Provider Portal. 
  2. Mail: PCHP Claims Appeals & Complaints 
    P.O. Box 560347 
    Dallas, TX 75356-9005 

Questions: 

  • HEALTHfirst (STAR): 1-888-672-2277 
  • KIDSfirst (CHIP or CHIP Perinate): 1-888-814-2352 

The status of an appeal can be viewed on the PCHP Provider Portal or by calling Provider Customer Service. A resolution will be mailed, and a copy will be accessible on the PHCP Provider Portal.

Complaints

Physicians and other professional providers may file written complaints involving:

  • Dissatisfaction or concerns about another physician and other professional providers
  • Operation of PCHP
  • Members, if the complaints are not related to a claim determination or Adverse Determination

Complaints related to claim determination or Adverse Determination should be submitted in accordance with the procedures set forth later in this section.

Please submit your complaint and all supporting documentation via: 

  1. Online: Save time and submit your appeal online through our Provider Portal. 
  2. Fax: 844-310-1823
  3. Mail: PCHP Claims Appeals & Complaints 
    P.O. Box 560347 
    Dallas, TX 75356-9005 

The complaint must include the provider’s name, date of the incident, and a description of the incident.

Questions: 

  • HEALTHfirst (STAR): 1-888-672-2277 
  • KIDSfirst (CHIP or CHIP Perinate): 1-888-814-2352