Community First might 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; or 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.
You will receive a letter telling you if a service or medicine has been denied. You will also receive an appeal form. You can appeal if you are not satisfied with the decision. You can also ask for an appeal if Community First denied payment of services in whole or in part.
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.
A Community First Member Services Representative can also help you file an appeal. Call toll-free 1-800-434-2347 for assistance.
APPEAL TIMEFRAMES
You must request an appeal within 60 days from the date on your notification 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 (5) 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 toll-free 1-800-434-2347.
You have the right to keep getting any current medical services Community First already approved while we process your appeal, if you file your appeal on or before:
• 10 days from the date you received our decision letter, or
• The date our decision letter says your medical services will be reduced or end.
If the services that are the subject of the appeal are not approved during the appeal, you may be responsible for the cost of the services you received during the appeal.
To learn more about the Appeals process, refer to your Member Handbook.
EXTERNAL MEDICAL REVIEW & STATE FAIR HEARING
If you are not satisfied with your appeal decision, you can request an External Medical Review and State Fair Hearing no later than 120 days after the date Community First mails you the decision appeal notice.
You also have the option to request a State Fair Hearing without an External Medical Review no later than 120 days after Community First mails you the appeal decision notice.
You can learn more about External Medical Reviews and State Fair Hearings by reading your Member Handbook or by visiting our External Medical Review and State Fair Hearing page.
Call us toll-free at 1-800-434-2347, email us at qmappeals@cfhp.com, or mail or fax this form to us.
Community First Health Plans, Inc.
Quality Management Resolution Unit
12238 Silicon Drive, Suite 100
San Antonio, TX 78249
Fax: (210) 358-6384