The processes outlined below apply to both non-emergency and emergency State Fair Hearings and External Medical Reviews.
A State Fair Hearing is when the Texas Health and Human Services Commission (HHSC) directly reviews our decisions with your medical care.
If you ask for a State Fair Hearing, you can also ask for an External Medical Review where independent health care experts review your request to receive services. This review is an optional, extra step you can take to get your case reviewed for free before your State Fair Hearing. It doesn’t change your right to a State Fair Hearing.
How To Request a State Fair Hearing and External Medical Review:
-Fill out the State Fair Hearing and External Medical Review Request Form mailed to you and mail or fax it back to us using the address or fax number at the top of the form; or
–Call us at (210) 227-2347 or toll free 1-800-434-2347; or
– Email us at qmappeals@cfhp.com.
You must make a request for a State Fair Hearing with or without an External Medical Review by 120 days from the date the internal appeals decision notice is mailed.
If you don’t ask for a State Fair Hearing with or without an External Medical Review by this date, you may lose your right to a State Fair Hearing. If you have a good reason, like receiving our notice late, we may be able to accept your appeal request after this date.
If you kept receiving services during your health plan appeal, you may be able to continue your services during your State Fair Hearing.
Make a request to continue getting services by 10 days from the date the internal appeals decision notice is mailed only if you got services during your health plan appeal. If you don’t ask for a State Fair Hearing and to keep your services by then, you will not continue to get your services, but you will have until 120 days from the date the internal appeals decision notice is mailed to ask for a State Fair Hearing with or without an External Medical Review.
To make the request, call us or check “Yes” on the State Fair Hearing and External Medical Request Form where it says, “Do You Want Your Services to Continue?”.
If you lose your State Fair Hearing, you may have to pay your health plan back for services provided to you during the fair hearing process. Community First Health Plans cannot ask you to pay them back for services you received without permission from HHSC.
What to Expect After You Request a State Fair Hearing
When you ask for a State Fair Hearing with or without an External Medical Review, a hearings officer will be placed in charge of your case.
You’ll get a Notice of Hearing in the mail within 10 calendar days of your request for a State Fair Hearing. It will tell you the date, time, and location of your hearing.
If you ask for an External Medical Review, it will happen before your State Fair Hearing. An External Medical Review doesn’t affect when your State Fair Hearing will be scheduled.
If you get an emergency State Fair Hearing, your hearing will be scheduled, and you will get a decision within three business days of your request.
If you request an emergency External Medical Review with your emergency State Fair Hearing, you’ll get the External Medical Review decision within 24 hours. You can choose whether you want to have the State Fair Hearing you requested.
About The External Medical Review
– HHSC will give your information to independent health care experts who will review your case.
– Only the information submitted for your health plan appeal will be used. You won’t be able to give new information for the review.
– The experts can agree with or change our decision. Their External Medical Review decision will be mailed to you in 15 calendar days or less.
– After you get your External Medical Review decision, you can choose if you want to also have the State Fair Hearing you requested.
– If you want to have your State Fair Hearing, the External Medical Review decision will be considered as evidence during your State Fair Hearing.
About The State Fair Hearing
-Most hearings are held by phone, but if you have a good reason, you can request to hold it in person.
– You have the right to see any information your health plan will use at the hearing. We’re required to send you this information within 10 calendar days from the date you requested the hearing.
– You can submit new facts about your case to HHSC. This information will be shared with your health plan prior to the State Fair Hearing.
– HHSC can agree with or change our decision in a State Fair Hearing decision. But, if you had an External Medical Review, the State Fair Hearing decision will not reduce your benefits below the External Medical Review decision.
– The written State Fair Hearing decision will be mailed to you within 90 calendar days of the date you asked for a State Fair Hearing.
– The decision will explain your right to have the case reviewed by an HHSC attorney if you disagree with the decision made about your services.
Need Help?
You or your representative can call us at (210) 227-2347 or toll free at 1-800-434-2347 to learn more about a State Fair Hearing and an External Medical Review.
If you have more questions about the State Fair Hearing process, call an HHSC ombudsman at 866-566-8989 or complete the online form at hhs.texas.gov/managed-care-help.
Review the State Fair Hearing and External Medical Review Request form you received/will receive via mail attached to our internal appeal decision notification letter below.
State Fair Hearing and External Medical Review Request Form – ENG
State Fair Hearing and External Medical Review Request Form – SPAN
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