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.

How do I ask for an appeal?
You can ask for an appeal by calling or writing to El Paso Health.  You can appeal or have someone else represent you.  If you choose to have someone else appeal on your behalf, you need to let us know in writing the name of the person you want to represent you. A doctor or other medical provider may be your representative. You can file your appeal by calling or writing to El Paso Health at the following:

El Paso Health
Attention: Health Services
1145 Westmoreland Drive
El Paso, TX 79925
Tel: 915-532-3778
Toll Free: 877-532-3778
Fax No.: 915-298-7866 or Toll Free Fax No. (844)298-7866

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
  • Any new information that will help with your case

When will I know if my appeal was approved or denied?
El Paso Health has 30 days to review your appeal and give you an answer of the decision. 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 the Member, and the Member’s representative.

Expedited Health Plan 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 or your representative can ask for an Expedited Appeal with El Paso Health 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.

Who can help me file an Expedited Appeal?
You can contact El Paso Health at  (915) 532-3778 ext. 1500 or toll free at (877)532-3778 ext. 1500 for assistance.

What happens if the health plan denies the request for an Expedited Appeal?
If El Paso Health denies your Expedited Appeal, you may request a State Fair Hearing.  You have 120 days from the date on the letter El Paso Health sends you notifying you that your appeal was denied.

 Can I ask for a State Fair Hearing?
Yes.  You or a representative can request a State Fair Hearing.  You may name someone to represent you by writing a letter to El Paso Health letting us know the name of the person you want represent you.

State Fair Hearing Process

What is a State Fair Hearing?
A Fair Hearing is a review by the Health and Human Services Commission (HHSC) of your dissatisfaction with the decision of your appeal.

When can a State Fair Hearing be requested?
If you disagree with El Paso Health’s decision, you have the right to a State Fair Hearing after exhausting El Paso Health’s appeal process, except in the case of an Expedited Fair Hearing. A State Fair Hearing request needs to be made within one-hundred and twenty days (120) days of the date on El Paso Health’s denial letter. If you do not ask for the State Fair Hearing within 120 days, you may lose you right to a State Fair hearing. You may ask for a State Fair Hearing by filling out the FILING FOR A STATE FAIR HEARING Form and mailing it or faxing it to the following:

 El Paso Health
Attention: Health Services
1145 Westmoreland Drive
El Paso, TX 79925
Fax No.: 915-298-7866
Fax Toll Free No.:  844-298-7866

Who can ask for a State Fair Hearing?
You can ask for a State Fair Hearing, or name someone to represent you by writing a letter to:

El Paso Health
Attention: Health Services
1145 Westmoreland Drive
El Paso, TX 79925

Your letter must include the name of the person you want to represent you. Please call (915) 532.3778 ext. 1500 or toll free at (877) 532-3778 ext. 1500 if you have questions regarding a fair hearing.

 What is the Timeframe for the Resolution of the State Fair Hearing?
HHSC will provide the final decision within 90 days from the date you asked for the hearing.

 What is the Process after a determination is made by the Hearing Officer?
If the determination of the appeal is to deny your service, you may be required to pay any services you received while your appeal was pending. If the determination is in your favor, El Paso Health will be responsible for payment of any services received while your appeal was pending.

If the determination of the appeal is in your favor, and you were not receiving any services while you were waiting on the decision of your appeal, El Paso Health will provide your service promptly.

You 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.  Their phone number is 915-585-5100 or toll free at 800-369-2792.  Their fax number is 915-544-3789. You can also contact El Paso Health at 915-532-3778 or toll free at 1-877-532-3778 for assistance.

You can learn more by reviewing the STAR Member Handbook here.