What can I do if my doctor asks for a service or medicine for me or my child that’s covered but Community First denies or limits it?
Community First may deny a health care service or medicine if it is not medically necessary. A medicine can also be denied:
– If the medicine does not work better than other medicines on the Community First Preferred Drug List.
– If there is another medicine that is similar that you must try first that you have not used before.
If you disagree with the denial, you can ask for an appeal.
How will I find out if services are denied?
You will receive a letter telling you if a service or medicine has been denied. You will also receive an appeal form.
When do I have the right to ask for an appeal?
You can appeal if you are not satisfied with our decision. You can also ask for an appeal if Community First denied payment of services in whole or in part.
What are the time frames for the appeal process?
You must request an appeal within 60 days from the date on your notice of the denial, reduction, or suspension of previously authorized services. You have the right to ask for an extension of up to 14 days if you want to provide more information in your appeal. A letter will be mailed to you within five days to tell you that we have received your appeal. We will then mail you our decision within 30 days. If Community First needs more information, we might ask for an extension of up to 14 calendar days. If we need an extension, we will call you as soon as possible to explain that there is a need for more information and that the delay is in your (the Member’s) interest. We will also send you written notice of the reason for delay. Community First will resolve your appeal as soon as possible based on your health condition and no later than the 14-day extension. If you are not happy with the delay, you may file a complaint by calling Member Services at 1-800-434-2347.
This information can also be found in your Member Handbook, click here.
How do I file an appeal? Does my request have to be in writing?
You may provide appeal information by phone, in writing, or in person. If you would like someone to file an appeal on your behalf, you may name a representative in writing by sending a letter containing their name to Community First. A doctor or other medical provider may be your representative. For more information, call Member Services at 1-800-434-2347.
You can send the appeal form and documents supporting your appeal to:
Community First Health Plans
Quality Management Resolution Unit
12238 Silicon Drive, Suite 100
San Antonio, TX 78249
Fax: 210-358-6384
Email: qmappeals@cfhp.com
Can someone from Community First help me file an appeal?
Yes, a Member Services Representative can help you file an appeal.