Grievances and Appeals
Read about:
Enrollee Appeals
For a description of the grievance and appeal process, please see the information for the enrollee's specific plan:
- Grievances and Appeals for Basic Health or Washington Health Program, Healthy Options/CHIP/Basic Health Plus, and Disability Lifeline
- Medicare Advantage Grievances and Appeals
Consent Document:
Glossary
Action: A decision by Community Health Plan to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits including the admission to or continued stay in a facility.
Appeal: A request for review of an action, as defined above.
An enrollee may file an appeal due to an adverse benefit determination or action by Community Health Plan.
An enrollee appeal may be submitted by the enrollee, a representative acting on behalf of and with permission from the enrollee, or a provider acting on behalf of and with written authorization from the enrollee within the timeframe outlined in the Medical Benefits Summary or the Evidence of Coverage for the enrollee's specific plan.
When assisting an enrollee with an appeal:
- Review their appeal processes and rights in the Medical Benefits Summary or the Evidence of Coverage for the enrollee's specific plan.
- For state program enrollees, obtain a signed authorization form
- For Medicare program enrollees, obtain a signed appointment of representative form
Provider Appeals
If a provider believes a decision made by Community Health Plan to be incorrect regarding an issue other than DRG pricing or Fee Schedule determinations that do not involve enrollee financial responsibility, a provider may appeal that decision.
Provider appeals must be in writing and submitted within 24 months from the date of the notice of denial.
An appeal must include:
- Enrollee name and member ID number
- Claim number (if applicable)
- Date of service
- All pertinent supporting documentation
- Reason for requesting the appeal
- Signed authorization (if filing on behalf of an enrollee)
Submit appeals to:
Community Health Plan
Attention: Appeals Department
720 Olive Way, Suite 300
Seattle, WA 98101
Fax 206-613-8984
DRG & Fee Schedule Disputes
For disputes related to DRG pricing or Fee Schedule determinations, see the Overpayment and Underpayment Recoveries section of your provider agreement or the Dispute Resolution or Overpayment and Underpayment Recoveries section of your facility agreement.
Submit DRG & fee schedule disputes to:
Community Health Plan
Attention: Provider Relations Department
720 Olive Way, Suite 300
Seattle, WA 98101
Fax 206-613-5018