CHIP Complaints and Appeals Process

You have the right to appeal. You can ask for an appeal if you are not happy with FirstCare CHIP's decision. You can call FirstCare Customer Service toll-free at 877-639-2447. Customer Service can help you with your appeal.

FirstCare CHIP will let you or your authorized representative know in writing when a covered service has been denied or limited.

You can ask for an appeal if you do not agree with what FirstCare has told you. You or your representative can ask for an appeal. You can ask for an appeal by phone or in writing.

FirstCare CHIP will send you a letter within five days after we get your verbal or written appeal. This lets you know that your written appeal has been received and will identify any information we may need to review your appeal.

FirstCare CHIP will review your request for appeal. You or your representative, and your doctor or health care provider will get a response. This will come within 30 days of when your written request is received.

Your appeal about an emergency or hospital stay will be decided in one business day once we have all the information followed by a letter within 72 hours.

You can ask for an appeal any time you disagree with FirstCare's decision. The decision can be about ending or limiting health services. If you are not happy with our decision, you can appeal.

You have only 180 days from the date on the letter to file an appeal. If you do not file your appeal within 180 days, the initial decision is final, and you have no further appeal rights with FirstCare. The appeal is not a court of law.

You can ask for an appeal by phone or in writing. Call FirstCare Customer Service at 877-639-2447 or write to us at:

FirstCare Health Plans
Attn: Complaints and Appeals Department
1206 W. Campus Drive
Temple, TX 76502

Or, fax to: 806-784-4319.

If you call FirstCare to request an appeal, you can follow up your phone call with a request in writing.

Yes. Call FirstCare Customer Service at 877-639-2447.

An IRO is a process for final administrative review of the medical necessity and appropriateness of health care provided or proposed to patients. The IRO's decision is binding on the health care plan. In circumstances involving a life-threating condition or when a request for an expedited appeal is denied, members are entitled to an immediate appeal to an IRO.

If a decision is made to end medical care, you have the right to appeal to an IRO. This is a process to make a final decision.

The IRO's decision is binding on the health care plan.

Any party whose appeal of an action is denied by FirstCare is entitled to seek review of that determination of an appeal by an IRO as follows:

• The member or the member's designated representative will be provided with information on how to appeal the denial of an adverse determination to an IRO and will be provided this information at the time of the denial of the appeal.
• The member or the member's designated representative will be provided an IRO Request Form which within four (4) months of the date of the denial must be completed and returned to FirstCare to begin the independent review process.
• In life-threatening situations, the member or the member's designated representative may contact FirstCare's Customer Service to request the review and provide the required information by phone.
• Retroactive reviews of adverse determinations are not subject to an IRO appeal process.
• The appeal process does not prohibit you from pursuing other appropriate remedies including injunctive relief, declaratory judgement, or relief available under law, if the requirement of exhausting the process for appeal and review places the member's health in serious jeopardy.

All requests for assistance in filing an IRO Request Form are to be directed to Customer Service. IRO Requests Form are to be mailed or faxed to:

FirstCare Health Plans
Complaints and Appeals Department
1206 W. Campus Drive
Temple, TX 76502
Phone: 877-639-2447
Fax: 806-784-4319

FirstCare Health Plans will comply with the IRO's determination with respect to the medical necessity or appropriateness of health care items and services, and the experimental or investigational nature of health care items and services for an enrollee.

The IRO completes the review, makes a decision and notifies all involved parties within:

• 45 days for non-life-threatening cases; or,
• 72 hours or less for life-threatening cases.

• If the member's request comes through FirstCare, the member is provided with FirstCare's IRO Request Form to request the independent review. If the member would like help completing the form, assistance can be obtained from FirstCare's Customer Service at 877-639-2447.
• FirstCare then sends the completed form to Independent Review Organization (IRO) for the IRO request.

Any person, including persons who have attempted to resolve complaints/appeals and appeals of an adverse determination through our procedures as outlined previously and who are dissatisfied with the resolution, may report their dissatisfaction to TDI. TDI will investigate the complaint and provide a determination within TDI established timelines. Members/providers may file a complaint to TDI by calling the toll-free number 800-252-3439. If you would like to make your request in writing send it to:

Texas Department of Insurance
P.O. Box 12030
Austin, TX 78711-2030
Fax: 512-490-1007
Online: tdi.texas.gov