Coverage Decisions, Grievance and Appeals

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You have a right to file a grievance, request an appeal or ask for a coverage decision. The following information will help you decide which one you need.

Coverage Decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs.

You or your doctor can call us if you are unsure whether we will cover a particular medical service you think that you need. In other words, if you want to know if we will cover a medical service or drug before you receive it, you can ask us to make a coverage decision for you. In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Call

If you have a question or need a status update, please call our Member Services Department toll free at 1-833-742-3125. TTY users should call 1-855-532-3740.

  • October 1—March 31, from 8 a.m.-8 p.m. Mountain Time (MT) 7 days a week.
  • April 1—Sept. 30, from 8 a.m.-8 p.m. Mountain Time (CT) Monday through Friday.

Write

El Paso Health Advantage Dual SNP (HMO D-SNP)
Attention: Complaints and Appeals
PO Box 97110
El Paso, TX 79997-1100
Fax: 915-298-7872

 

Grievance

You can submit a grievance if you have a complaint about us or if you are dissatisfied with the care or treatment you receive from our network providers.

Call 

If you have a complaint or need a status update, please call our Member Services Department toll free at 1-833-742-3125. TTY users should call 1-855-532-3740.

  • October 1—March 31, from 8 a.m.-8 p.m. Mountain Time (MT) 7 days a week.
  • April 1—Sept. 30, from 8 a.m.-8 p.m. Mountain Time (CT) Monday through Friday.

You, a representative (with appropriate authorization), or your treating physician, may submit a complaint. Complaints must be submitted orally or in writing within 60 calendar days from the date of the incident.

Write

El Paso Health Advantage Dual SNP
Attention: Complaints and Appeals Department
PO Box 97110
El Paso, TX 79997-1100
Fax: 915-298-7872

All grievances regardless of how the complaint is submitted, must be responded to in writing. They will be investigated as expeditiously as the case requires, based on your health status, but no later than 30 days of receipt of the request or within 24 hours for expedited grievances. We may take a 14-day extension if you request the extension or if we justify a need for additional information and how the delay is in your best interest.

You can also contact Medicare

You can submit a complaint about us directly to Medicare. To submit an online complaint to Medicare, go to: https://www.medicare.gov/MedicareComplaintForm/home.aspx

 

Appeals

You can request an appeal if we deny coverage or payment for a medical service, or item that you think we should cover or pay for. You can ask for a standard appeal or you can ask us to make a quick decision, this is called an “expedited” request if we have denied coverage that is not related to payment for services you already received.

Call

If you have a complaint or need a status update, please call our Member Services Department toll free at 1-833-742-3125. TTY users should call 1-855-532-3740.

  • October 1—March 31, from 8 a.m.-8 p.m. Mountain Time (MT) 7 days a week.
  • April 1—Sept. 30, from 8 a.m.-8 p.m. Mountain Time (CT) Monday through Friday.

You, a representative, or your treating physician, may submit an appeal. Appeals must be submitted orally or in writing within 60 calendar days from the date of the decision.

Write

El Paso Health Advantage Dual SNP (HMO D-SNP)
Attention: Complaints and Appeals
PO Box 97110
El Paso, TX 79997-1100
Fax: 915-298-7872

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

We will authorize or provide the service or benefit as expeditiously as the case requires, based on your health status, but no later than 30 days of receipt of the request or within 72 hours for expedited appeals. We may take a 14-day extension if you request, if we justify that it is in your best interest and request additional information from your provider; or due to circumstances beyond our control.

 

How to obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed with El Paso Health

To obtain an aggregate number of El Paso Health grievances, appeals and exceptions, please call Member Services please call our Member Services Department toll free at 1-833-742-3125. TTY users should call 1-855-532-3740.

  • October 1—March 31, from 8 a.m.-8 p.m. Mountain Time (MT) 7 days a week.
  • April 1—Sept. 30, from 8 a.m.-8 p.m. Mountain Time (MT) Monday through Friday.

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