Appeals

What is an Appeal?

An Appeal is the type of complaint you make when you want Physicians Health Choice to reconsider and change a decision made about what services or benefits are covered for you; or what Physicians Health Choice paid for a service or benefit. For example, you can file an appeal if Physicians Health Choice:

• refuses to cover or pay for services you think should be covered
• or a plan provider refuses to provide a service you think should be covered,
• or a plan provider reduces services or benefits you have been receiving
• is ending your coverage of a service or benefit too soon, you can file an appeal.

Standard appeals are processed in 30 days and can be submitted to:

Physicians Health Choice
Attn: Appeals Dept.
5800 Northwest Parkway, Suite 125
San Antonio, TX 78249
Fax: 1-877-757-8889

If you would like to designate someone else to submit an appeal on your behalf, please download, print and fill out the Appointment of Representative form.

There is a special type of appeal that applies only to hospital discharges and the discontinuation of home health care, skilled nursing facility and comprehensive outpatient rehabilitation facilities. Also known as an Expedited Appeal, these are processed within 72 hours. If you think coverage of your hospital stay or services is ending too soon, you can appeal immediately to your state’s Quality Improvement Organization (QIO). A QIO is a group of health professionals in your state that are paid to handle this type of appeal from Medicare patients.

• Texas Medical Foundation (TMF) Health Quality Institute
  Bridgepoint I, Suite 360
  5918 West Courtyard Dr.
  Austin, TX 78730-5036
  1-800-725-8315

If you make this type of appeal, your stay may be covered during the time period the QIO uses to make its determination. You have a very limited amount of time to appeal. Please refer to Section 11 of the Physicians Health Choice Evidence of Coverage, contact Physicians Health Choice Customer Service at 1-866-550-4736 (TTY 711), October 15, 2011 – March 1, 2012: 8 a.m. – 8 p.m., 7 days a week; and March 2, 2012 – October 14, 2012: 8 a.m. – 8 p.m., Monday – Friday, or the TMF Health Quality Institute at 1-800-725-9216 for instructions.

For more information on appeals, refer to your Evidence of Coverage.

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