If you disagree with a decision on your plan’s coverage or payment, you can file an appeal. We’ll review the appeal and make a ruling on the decision. If you have a complaint or are dissatisfied with service, you can file a grievance with the health plan, provider or facility.
CHRISTUS Health Plan
Attn: Appeal and Grievance Dept.
PO Box 169009
Irving, TX 75016
If you disagree with a coverage or payment decision, you can file an appeal. You have 60 calendar days from the date of the denial notice to file a standard appeal. We can extend the timeframe if the member shows good cause. For Medicare Parts C and D, you can file an appeal when:
If you have a complaint or are dissatisfied with the way a health plan, prescription drug plan or delegated entity provides health care services, you can file a grievance. For example:
Members, appointed representatives (a
friend, advocate, guardian or health care proxy), legal representatives of a
member’s estate and providers can file an appeal for Medicare Part C or Part D
An Appointment of Representative (AOR) form or other equivalent notice is required when someone files an appeal on behalf of a member. Both the member and the representative (including attorneys) must complete, sign and date it. An AOR form is not required for expedited and pre-service appeals that are requested by the member’s physician or provider.
Instead of an Appointment of Representative form, members can also provide equivalent written notice. This notice must include:
expedited or fast appeal can be filed when the member or his/her physician
believes that waiting for a decision under the standard time frame could place
the member’s life, health or ability to regain maximum function in serious
Expedited appeals may not be requested for cases that only involve a claim for payment for services already received. However, if a case includes both a payment denial and a pre-service denial, you have a right to request an expedited appeal for the pre-service denial.
An Appointment of Representative form is not required for expedited and pre-service appeals that are requested by the member’s physician or provider.
Members can request an expedited grievance when:
For Part C redetermination (appeals), a standard appeal decision is issued within 60 calendar days after receiving the request. A standard pre-service appeal will be completed within 30 calendar days from receipt. If CHRISTUS Health Plan upheld or partially overturned the appeal request, it will submit a written explanation with complete case file to the independent review entity (MAXIMUS Federal Services) contracted by CMS no later than:
For Part D coverage redetermination (appeals), a standard appeal decision is issued within seven (7) calendar days after receiving the request. Learn more about Part D Coverage Determinations.
For expedited appeals, the plan will issue a decision as quickly as possible and no later than 72 hours after receiving the request.
CHRISTUS Health Plan will respond to standard grievances within 30 days from the grievance receipt. For expedited grievances, we will respond within 24 hours of receipt.
CHRISTUS Health Plan is required to provide information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with the health plan.
CHRISTUS Health Plan Generations
Attn: Appeal and Grievance Department
P.O. Box 169009
Irving, Texas 75016
You can also submit feedback about your Medicare Advantage plan by completing a Medicare Complaint Form. Find more information about Medicare appeals or call 1-800-MEDICARE (1-800-633-4227) or 1-866-653-4261 (for TTY users) 24 hours a day, 7 days a week. Say “publications” for a free copy of your Medicare rights and protections.
H1189_MM143 pending approval
Last Updated: 2/23/17