You can ask for an appeal by calling or writing to El Paso Health.  You can appeal or have someone else represent you.  If you choose to have someone else appeal on your behalf, you need to let us know in writing the name of the person you want to represent you. A doctor or other medical provider may be your representative. You can file your appeal by calling or writing to El Paso Health at the following:

You can ask for an appeal if you do not agree with El Paso Health on a decision made on the covered medical services you asked for.  You have the right to appeal if your services were not approved, or only part of the services you asked for were approved or reduced. You have 60 days from the date on your denial letter to ask for the appeal.

You can ask for an appeal by calling or writing to El Paso Health.  You can appeal or have someone else represent you.  If you choose to have someone else appeal on your behalf, you need to let us know in writing the name of the person you want to represent you. A doctor or other medical provider may be your representative. You can file your appeal by calling or writing to El Paso Health at the following:

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925

STAR

Tel: 915-532-3778
Toll Free: 1-877-532-3778

 

STAR+PLUS
Toll Free: 1-833-742-3127

Fax No.: 915-298-7872 or Toll-Free Fax No. (844)298-7872

If El Paso Health denies your appeal, you may request an External Medical Review (EMR) and State Fair Hearing (SFH) or just a State Fair Hearing.  You have 120 days from the date on the letter El Paso Health sends you notifying you that your appeal was denied.

If El Paso Health denies your appeal, you may request an External Medical Review (EMR) and State Fair Hearing (SFH) or just a State Fair Hearing.  You have 120 days from the date on the letter El Paso Health sends you notifying you that your appeal was denied.

El Paso Health will notify you by telephone or fax of the emergency appeal decision within 72 hours if the emergency appeal request meets the criteria of the seriousness of your condition.

For ongoing emergency or denial of continued hospitalization, El Paso health will notify you no later than one (1) business day You will be notified by telephone or fax.  You will also receive a letter within three working days following the phone or fax notification of the decision to your appeal.

An Emergency  Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

You, your provider or your representative can ask for an emergency appeal with El Paso Health orally or in writing. You can call El Paso Health at 915-532-3778 or toll free at 1-877-532-3778 for STAR or toll free at 1-833-742-3127 for STAR+PLUS. You can also submit it via fax at 915-298-7872 or to:

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925

 

You can contact El Paso Health at (915) 532-3778 or toll free at (877) 532-3778 for STAR and (833) 742-3127 for STAR+PLUS and a Member Advocate can assist you.

If El Paso Health determines that your emergency appeal request does not meet the emergency criteria we will notify you immediately and will process the appeal as Standard and provide you a response within thirty (30) Calendar days.

Yes.  You or a representative can request a State Fair Hearing.  You may name someone to represent you by writing a letter to El Paso Health letting us know the name of the person you want represent you.

If you, as a member of El Paso Health, disagrees with our internal appeal decision, you have the right to ask for an External Medical Review (EMR). An EMR is an optional, extra step you can take to get the case reviewed for free before the State Fair Hearing. You may name someone to represent you by writing a letter to El Paso Health telling us the name of the person the Member wants to represent you. A provider may be your representative. You or your representative must ask for the External Medical Review within 120 days of the date El Paso Health mails the letter with the internal appeal decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review. To ask for an External Medical Review, your or your representative should either:

• Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to El Paso Health’s appeal decision Notice of the Internal Appeal Decision letter and mail or fax it to El Paso Health by using the address or fax number at the top of the form.
• Call El Paso Health at 915-532-3778 or toll free at 1-877-532-3778 for STAR Medicaid or toll free at 1-833-742-3127 for STAR+PLUS.
• Email the El Paso Health at Complaints&AppealsTeam@elpasohealth.com

If you ask for an External Medical Review within 10 days from the time you get the appeal decision from El Paso Health, you have the right to keep getting any service El Paso Health denied, at least until the final State Fair Hearing decision is made. If you do not request an External Medical Review within 10 days from the time you get the appeal decision from El Paso Health, the service El Paso Health denied will be stopped.

You may withdraw your request for an External Medical Review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing your External Medical Review request. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an External Medical Review during your appeal processes related to Adverse Benefit Determinations based on functional necessity or medical necessity. An External Medical Review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.

Once the External Medical Review decision is received, you have the right to withdraw the State Fair Hearing request. It is your responsibility, your authorized representative, or your LAR to withdraw a State Fair Hearing request.  If you, your authorized representative, or your LAR does not withdraw the State Fair Hearing request, regardless of the EMR decision, you, your authorized representative, or your LAR is required to attend the State Fair Hearing.

You can submit your request orally by calling El Paso Health at 915-532-3778 or
Toll-Free at 877-532-3778 and a Member Service Representative or a Member Advocate can help with your request. You also have the option to submit your request in writing either by mail or fax to:

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Fax: 915-298-7872 or Toll-Free: 877-298-7872

After exhausting El Paso Health’s Internal appeals process, you, your authorized representative or your Legally Authorized Representative (LAR) may contact El Paso Health’s Member Services Department or Member Advocate at (915) 532-3778 or toll free at 1-877-532-3778 for STAR or toll free at 1-833-742-3127 for STAR+PLUS to request an External Medical Review (EMR)

A Fair Hearing is a review by the Health and Human Services Commission (HHSC) of your dissatisfaction with the decision of your appeal.

If you disagree with El Paso Health’s appeal decision, you have the right to a State Fair Hearing after exhausting El Paso Health’s appeal process. A State Fair Hearing request needs to be made within one-hundred and twenty days (120) days from the date on the letter you received from El Paso Health letting you know of the decision on your appeal.  If you do not ask for the State Fair Hearing within 120 days, you may lose your right to a State Fair Hearing. State Fair Hearing may also be requested orally by calling 915-532-3778 or toll free at 1-877-532-3778 for STAR or toll free at 1-833-742-3127 for STAR+PLUS.  You may ask for a State Fair Hearing by filling out the FILING FOR A STATE FAIR HEARING Form and mailing it or faxing it to the following:

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Fax No.: 915-298-7872

You can ask for a State Fair Hearing. You may also name someone to represent you by writing a letter to El Paso Health with the name of the person you want to represent you. A provider may be your representative.

The State Fair Hearing request can be mailed to the following address

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Fax No.: 915-298-7872

Or call us at:

STAR: 915-532-3778, or Toll Free 1-877-532-3778

STAR+PLUS : Toll Free  1-833-742-3127

You or your representative can call El Paso Health at  915-532-3778 or toll free at 1-877-532-3778 for STAR, or toll free at 1-833-742-3127 for STAR+PLUS with any question about the State Fair Hearing Process or status of your State Fair Hearing request

If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing.  Most State Fair Hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied.

HHSC will give you a final decision within 90 days from the date you asked for the hearing.