X hits on this document

539 views

0 shares

0 downloads

0 comments

153 / 190

Exhibit L You have the right to appeal this decision. There are two types of appeals: standard and expedited.

Standard Appeal Process A standard appeal will be resolved within 30 days. Please submit a copy of your denial notice and a brief explanation of your situation, or other relevant information to the address listed below, or call:

Community Health Plan Attn: Member Services 1000 S. Fremont Avenue, Building A-9 East 2nd Floor, Unit 4 Alhambra, CA 91803-8859 1-(800) 475-5550 or TTY/TDD 1-(626) 299-7265 Fax Number: (626) 299-7259

Expedited/72 hour Appeal Process Your health plan makes every effort to resolve your appeal as quickly as possible. In some cases, you have the right to an expedited appeal when a delay in the decision making might pose an imminent and serious threat to your health, including but not limited to severe pain, potential loss of life, limb, major bodily function, or the normal timeframe for the decision making process would be detrimental to your life, or health or could jeopardize your ability to regain maximum function. If you request an expedited appeal, your health plan will evaluate your appeal and health condition to determine if your grievance qualifies as expedited. If so, your appeal will be resolved within 72 hours. If not, your appeal will be resolved within the standard 30 days.

You or someone you designate may submit your expedited appeal verbally or in writing. Specifically state that you want an expedited appeal or that you believe your health might be seriously jeopardized by waiting for the standard appeal process.

Your health plan will make a decision on your expedited appeal and will notify you in writing of the decision within 72 hours of receiving your appeal.

For an Expedited Appeal: Call: 1-(800) 475-5550 or TTY/TDD 1-(626) 299-7265 Community Health Plan will document and process your appeal.

Write:

Community Health Plan Attn: Member Services 1000 S. Fremont Avenue, Building A-9 East 2nd Floor, Unit 4 Alhambra, CA 91803-8859 Fax Number: (626) 299-7259

Department of Managed Health Care

CHP HFP NOA Version 1.1.04

2

Document info
Document views539
Page views539
Page last viewedThu Dec 08 22:24:38 UTC 2016
Pages190
Paragraphs4697
Words16946

Comments