Healthy Options, SCHIP, Basic Health Plus Grievance and Appeal Process

As a Community Health Plan member, you have the right to file a complaint or appeal a decision about a complaint resolution or a denied claim or service.

A complaint is anything that you are not happy with except for a denied service or referral for service. If you have a complaint, you can write to us or call us at the number above. We will let you know we got your written complaint within 5 days of receiving it. We will write to you within 14 days with an answer.

An appeal is when you ask us to review our decision because you do not agree with a complaint resolution, a denied service or request for a service.

HOW TO FILE A COMPLAINT OR AN APPEAL

You can file a complaint or appeal in writing, in person, or over the phone by calling us at the number above. Include your name; address; phone number; Health Plan's I.D. number and why you are asking for the appeal. You can send anything with your appeal that will help your case. Send your written appeal or complaint to:
Community Health Plan
Attn: Appeals Department
720 Olive Way, Suite 300
Seattle, WA 98101
Fax: (206) 613-8983

APPOINTING A PERSONAL REPRESENTATIVE

At any time, you can have someone act on your behalf. This person can be anyone, including an attorney or provider. We must get your written consent to let the person represent you before the person can act on your behalf.

EXPEDITED (RUSH) APPEAL

You can ask for an expedited (rush) appeal if you or your doctor(s) feel that not getting care right away could cause an emergency or put your life in danger, or put at risk your ability to get, keep, or get back maximum functioning. Our Medical Director will decide if the review needs to be expedited (rushed). If approved, we will make a decision not more than 72 hours from the time we get the request. If we deny your request for an expedited appeal, we will process it as a "standard" appeal (see below). We will call you or your doctor to let you know our decision and send a letter within 2 days. You may file a complaint if we do not process your appeal as an expedited (rush) appeal.

STANDARD APPEAL

There are time limits for filing an appeal:

  1. You must file the appeal within 90 days from the date of a denial or complaint resolution.
  2. If we are ending or reducing a service you are currently getting, and you want to continue getting the service during the appeal process, you only have 10 days to file the appeal. In this case, we will provide the service while we review the appeal or until the original approval ends, whichever is sooner. If we deny the service, you may have to pay for any services you continued to receive.


We will let you know we got your appeal within 5 days of getting it. A Grievance Committee reviews your appeal. The Grievance Committee is made up of people who were not part of the original denial decision. They will review your case and make a decision. If you want to come to the meeting or join by phone, call us as soon as possible. You can ask anyone to help you with your case. If someone is speaking for you, we must have your written approval before the meeting. If you ask, we will send you a copy of all the documents used to make our decision.

Your appeal information is confidential. We will give you an answer on your appeal in 14 days. If not, we will write to you and tell you why we need more time. Without your written consent, the decision will not take longer than 30 days from the date we got your request.

DSHS HEARING

If you do not agree with our decision, you have the right to ask the Department of Social and Health Services (DSHS) for a hearing. You must complete our appeal process before asking for a hearing. You must ask for a hearing within 90 days of the date that we denied your appeal. If your health requires a quick decision, you can ask for an expedited (rushed) hearing.

To ask for a DSHS hearing:

  • Call the Office of Administrative Hearings (www.oah.wa.gov) at 1-800-583-8271, or write to them at P.O. Box 42489, Olympia, Washington 98504-2489.
  • Tell the Office of Administrative Hearings the reason you want a hearing and that you have already appealed our first decision.
  • You may consult with a lawyer or have another person represent you at the hearing. If you need help finding a lawyer call the NW Justice CLEAR line at 888-201-1014, weekdays from 9:15 a.m. until 12:15 p.m., and Tuesdays from 3:30 p.m. until 6:15 p.m., or visit their web site at www.nwjustice.org.


INDEPENDENT REVIEW

If you do not agree with the DSHS Hearing decision, you can ask that an Independent Review Organization (IRO) review your case. You do not have to pay for the review. You must ask for the IRO review within 180 days from the date of the Hearing decision. We will help you file an IRO by phone if you call us at the number listed above or send your written request for an IRO review to us. If your health requires a quick decision, you can ask for an expedited (rushed) IRO review.

The IRO that reviews your case is not part of Community Health Plan. When the IRO makes a decision, they will contact you and tell you their decision.

DSHS BOARD OF APPEALS

If you do not agree with the IRO decision, you can appeal to the DSHS Board of Appeals. The decision of the DSHS Board of Appeals is final. Your request must be in writing and you must ask for the review within 21 days from the date the IRO mailed their decision. Your request must include all information about the denied service and any new information that may help your case. Mail to:
DSHS Board of Appeals
P.O. Box 45803
Olympia, WA 98504-5803
Toll free: 1-877-351-0002
Teletype (TTY): 1-360-664-6178