When do I have a right to ask for an appeal?
You can ask for an appeal if you do not agree with El Paso Health on a decision made on the covered medical services you asked for. You have the right to appeal if your services were not approved, or only part of the services you asked for were approved or reduced. You have 60 days from the date on your denial letter to ask for the appeal.
There are four (4) types of appeals:
- Standard Appeal: An appeal that does not involve urgent care such as emergency care, life-threatening conditions, or continued hospitalization.
- Expedited Appeal: An expedited appeal is available for emergency care, life-threatening conditions, and for members who are hospitalized
- Specialty Appeal: This appeal is available only after El Paso Health reviews your appeal and did not approve it.
- Acquired Brain Injury Appeal: An appeal of denied services concerning an acquired brain injury.
How do I ask for an appeal?
You or someone acting on your behalf, your provider of record and the health care provider who rendered the services, if different from your provider of record have the right to appeal the denial of your health care services. You can file an appeal orally or in writing. Every oral appeal received will be confirmed by El Paso Health. Aone page appeal form will be mailed to you within 1 working day of receipt. You can appeal by calling or writing to El Paso Health at:
El Paso Health
Attention: Health Services
1145 Westmoreland Drive
El Paso, TX 79925
Tel: 915-532-3778 X 1536
Toll Free: 877-532-3778 X 1536
Fax No.: 915-298-7866 or toll free fax number is 844-278-7866
What do I need to ask for an appeal?
You will need to give us the following information:
- A letter letting us know the reason you want to appeal
- A copy of the denial letter you received from El Paso Health
- The information listed in your letter of acknowledgement
When we receive your appeal, El Paso Health will let you know in writing within five days that we have received your appeal.
When will I know if my appeal was approved or denied?
El Paso Health will give you an answer to your appeal in the following timeframes:
- Standard Appeal: 30 days from when we received your appeal.
- Expedited Appeal: One working day from the date we receive all the information necessary to complete your appeal. The notification will be made by telephone or electronic transmission and provide you with a written determination within three (3) working days of the initial telephonic or electronic notification.
- Retrospective (Claim) Appeal: 30 calendar days after receipt of appeal. However, we may extend this deadline once for a period not to exceed 15 days.
- Acquired Brain Injury Appeal: Not later than three (3) business days after the date on which the individual submits the appeal. The notification of the determination must be provided through a direct telephone contact to the individual making the request. We will provide a written determination within 30 calendar days of receipt of the appeal.
You can call El Paso Health at 915-532-3378 or toll free at 1-877-532-3778 if you have any question about your appeal.
What happens if my appeal is denied?
If El Paso Health denies your appeal, your doctor can ask for a Specialty Review. He must have a good cause for asking for the Specialty Review and has 10 days to request the Specialty Review. The Specialty Review will be completed within fifteen (15) working days of the date the health care Provider requested the Specialty Review. Notification of the determination will be provided in writing by letter to you.
Expedited El Paso Health Appeal
What is an Expedited Appeal?
An Expedited Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.
How do I ask for an Expedited Appeal?
You, someone acting on your behalf, or your doctor may file an Expedited Appeal with El Paso Health.
Does my request have to be in writing?
No. You can request an Expedited Appeal orally or in writing.
What are the timeframes for an Expedited Appeal?
El Paso Health will let you know based on the seriousness of your condition, but in no case later than one working day from when El Paso Health receives all the information necessary to complete the Expedited Appeal. You will be notified by telephone or fax. You will also receive a letter within three working days following the phone or fax notification of the decision to your appeal.
What happens if El Paso Health denies the request for an Expedited Appeal?
You can request an external review by an IRO.
If the Member has a life-threatening condition, the Member, or someone acting on the Member’s behalf, and the provider of record can request an immediate review by an IRO, and is not required to follow our internal appeal process. You can ask for an immediate review by an IRO by calling 1-888-866-6205. You can also submit your expedited appeal to the following:
Mail: MAXIMUS Federal Services
State Appeals East
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
For an expedited review, Maximus will give you a decision as soon as possible based on the seriousness of your condition and not later than 72 hours of receiving your request. The notice can be by phone, but will be followed in writing within 48 hours.
What is an Independent Review Organization (IRO)?
The IRO is an independent, outside review of health care services that are denied by your health plan. The purpose of the external review, is to find out if El Paso Health made the right decision on the service or treatment you requested.
How do I ask for a review by an IRO?
You have four months to request a review by an IRO. You must first appeal to El Paso Health. If El Paso Health denies your request, you can request a review by an IRO by completing and signing the Request for Review by an HHS Federal External Review Request form included with your denial letter. You can also submit your appeal online at https://www.externalappeal.com/ferpportal.
The external review will be completed by MAXIMUS Federal Services. When MAXIMUS receives your request, they will notify us and we’ll send them all of the case information for review. If you send them any more information they’ll share it with us. We may change our decision. If not, the IRO will continue the review. You’ll receive a letter with their decision. If MAXIMUS decides to overturn our decision, we will provide coverage or payment for your health care item or service.
You can call MAXIMUS at 1-888-866-6205 if you have questions about your external review.
What are the timeframes for this process?
The IRO (MAXIMUS) will complete the review within 45 days of receipt for a Standard Appeal.
What happens after a decision is made by the IRO?
If the decision is made in your favor, El Paso Health will comply with the IRO’s decision and authorize the disputed services promptly. El Paso Health will be responsible for the payment of services.
If the IRO agrees that the healthcare services were not medically necessary or appropriate, then services will not be covered by the health plan.
The Member may qualify for free or low cost legal services by contacting the Texas Rio Grande Legal Aide located at 1331 Texas Avenue, El Paso, TX 79901, at phone number 915-585-5100, toll free at 800-369-2792, or fax at 915-544-3789. You can also contact El Paso Health at 915-532-3778 or toll free at 1-877-532-3778 for assistance.
If you wish to file a complaint with El Paso Health, you can contact us at:
El Paso Health
Attn: Complaints and Appeals Unit
1145 Westmoreland Dr.
El Paso, TX 79925
If you wish to file a complaint with TDI, you can contact TDI at:
Texas Department of Insurance
Consumer Protection (111-1A)
P.O. Box 149091 Austin, Texas 78714-9091
Fax: (512) 475-1771
You can learn more by reviewing the CHIP Member Handbook here.