果冻传媒

What is an Appeal?

If 果冻传媒 denies, limits, reduces, suspends, or stops a service, you have the right to ask us to review our decision. This is called an Appeal.

You may file an Appeal phone or by mail.

How do I file an Appeal?
You may file an Appeal by:

Phone

• Local: 713.295.2294
• Toll-free: 1.888.760.2600聽 or (TTY 7-1-1)

Mail
果冻传媒, Inc.
Attention: Medical Affairs 鈥� Medical Appeals Department
4888 Loop Central Drive, Suite 600
Houston, TX 77081

Behavioral Health Appeals
果冻传媒 Texas, Inc.
Attention: Medical Affairs 鈥� Behavioral Health Appeals
P.O. Box 301411
Houston, TX 77230

If you need help completing your Appeal, Member Services can assist you by call or toll-free at 1.888.760. 2600 or (TTY 7-1-1).

Appeal Forms
If you need an Appeal Form or would like assistance completing one, please contact Member Services at聽713.295.2294聽or toll-free at聽1.888.760.2600 or (TTY 7-1-1). A Member Services representative can provide an Appeal Form and answer any questions about the Appeals process.

How long do I have to file an Appeal?
You have 60 days from the date of the denial notice to ask for an appeal. You may request an Appeal after receiving notice of our decision.

If you want your current authorized services to continue while your Appeal is reviewed, you must request your Appeal by the later of:

• 10 calendar days after we mail the notice of action, or
• The effective date of the action.

How long will the Appeal take?
果冻传媒 will complete the standard Appeal process within:

• 30 calendar days聽after receiving your Appeal.

The review may be extended by聽up to 14 calendar days听颈蹿:

• you request the extension, or
• 果冻传媒 determines additional information is needed and the delay is in your best interest.

If an extension is needed, we will notify you in writing.

Emergency Appeals
If waiting for a standard Appeal could seriously jeopardize your life, health, or ability to regain maximum function, you may request an聽Emergency Appeal.

Emergency Appeals may be requested orally or in writing.
If approved for expedited review:

• Decision made within聽72 hours聽after receiving all necessary information.
• Certain emergency situations receive a response within聽one business day.

If your request for an Emergency Appeal is denied, your Appeal will automatically be processed as a standard Appeal.

State Fair Hearing
If you disagree with the Appeal decision, you may request a State Fair Hearing.

Requests must be made within聽120 days聽after 果冻传媒 mails the Appeal decision notice.

Need Help?
A 果冻传媒 Member Advocate can help you:

• File an Appeal
• Check the status of your Appeal
• Answer questions about the Appeals process
• Complete Appeals forms

Call Member Services at 713.295.2294 or toll-free at 1.888.760.2600 or (TTY 7-1-1).

For more information about the Appeals process, see page 58 of the Member handbook.