MEDICAID Appeals Process

MEDICAID Appeals Process

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:

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.

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: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Tel: 915-532-3778
Toll Free: 877-532-3778
Fax No.: 915-298-7872 or Toll-Free Fax No. (877)298-7872

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 915-532-3778 or toll free at 1-877-532-3778 if you have any question about your appeal.

If El Paso Health denies your 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. See below “State Fair Hearing Process”

Emergency Health Plan 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 Emergency 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.

An Emergency  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.

You or your representative can ask for an Emergency Appeal with El Paso Health orally or in writing.

You can contact El Paso Health at (915) 532-3778 or toll free at (877)532-3778 and a Member Advocate can assist you.

The emergency appeal will be treated as a regular appeal and El Paso Health has 30 days to resolve.

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.

External Medical Review Process

If you, as a member of El Paso Health, disagrees with our internal appeal decision, you have the right to ask for an External Medical Review (EMR). An EMR is an optional, extra step you can take to get the case reviewed for free before the State Fair Hearing. You may name someone to represent you by writing a letter to El Paso Health telling us the name of the person the Member wants to represent you. A provider may be your representative. You or your representative must ask for the External Medical Review within 120 days of the date El Paso Health mails the letter with the internal appeal decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review. To ask for an External Medical Review, your or your representative should either:

  • Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to El Paso Health’s appeal decision Notice of the Internal Appeal Decision letter and mail or fax it to El Paso Health by using the address or fax number at the top of the form.
  • Call the El Paso Health at 915-532-3778 or toll free at 1-877-532-3778.
  • Email the El Paso Health at Complaints&AppealsTeam@elpasohealth.com

If you ask for an External Medical Review within 10 days from the time you get the appeal decision from El Paso Health, you have the right to keep getting any service El Paso Health denied, at least until the final State Fair Hearing decision is made. If you do not request an External Medical Review within 10 days from the time you get the appeal decision from El Paso Health, the service El Paso Health denied will be stopped.

You may withdraw your request for an External Medical Review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing your External Medical Review request. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an External Medical Review during your 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, you have the right to withdraw the State Fair Hearing request. If you

continue with the State Fair Hearing, you can also request the Independent Review Organization be present at the State Fair Hearing. You can make both of these requests by contacting the El Paso Health at 1145 Westmoreland Drive, El Paso Texas 79925 or call (915) 532-3778 (toll free: 877-532-3778).   or the HHSC Intake Team at EMR_Intake_Team@hhsc.state.tx.us.

External Medical Review information can also be found in the STAR Member Handbook here.

You can submit your request orally by calling El Paso Health at 915-532-3778 or
Toll-Free at 877-532-3778 and a Member Service Representative or a Member Advocate can help with your request. You also have the option to submit your request in writing either by mail or fax to:

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Fax: 915-298-7872 or Toll-Free: 877-298-7872

After exhausting El Paso Health’s Internal appeals process, you, your authorized representative or your Legally Authorized Representative (LAR) may contact El Paso Health’s Member Services Department or Member Advocate at 1-877-532-3778 to request an External Medical Review (EMR). An EMR is an optional, extra step you can take to get the case reviewed for free before the State Fair Hearing. You or your authorized representative or LAR cannot request only an External Medical Review. You can request either (1) an External Medical Review Hearing and a State Fair Hearing or (2) only a State Fair Hearing.
You can also contact us for status of External Medical Review or any questions regarding this process.

State Fair Hearing Process

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

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. A State Fair Hearing request needs to be made within one-hundred and twenty days (120) days from the date on the letter you received from El Paso Health letting you know of the decision on your appeal.  If you do not ask for the State Fair Hearing within 120 days, you may lose your right to a State Fair hearing. State Fair Hearing may also be requested orally by calling (915) 532-3778 or toll free at (877) 532-3778.  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: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Fax No.: 915-298-7872
Fax Toll Free No.:  877-298-7872

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

El Paso Health
Attention: Complaints and Appeals Department
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.

If you, as a member of the health plan, disagree with our internal appeal decision, you have the right to ask for a State Fair Hearing. You or your representative can call El Paso Health at 915-532-3778 or toll free at 1-877-532-3778. A Member Services Representative or a Member Advocate will be able to assist you in this process.

HHSC will provide the final decision within 90 days from the date you asked for the hearing.

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.