Appeals & Grievances
We take your concerns seriously and consider them opportunities to improve care and service to our enrollees. Following is an overview of the Community HealthFirst Appeals and Grievance Policies.
Click Here - Appeals & Grievances Policy Handbook
Appeals
An appeal is the type of complaint you make when you want us to reconsider a decision we have made about what benefits are covered under your plan or what we will pay. For example, you might appeal if:
- you feel we have not paid for a particular medical procedure or other service you think should be covered;
- your plan has coverage for prescription drugs (Part D) and we will not approve payment for care or prescription drug you believe should be covered (please see the Coverage Determination section below on this page);
- your plan has coverage for prescription drugs (Part D) and we are stopping payment for care or Part D benefit you need (please see the Coverage Determination section below on this page).
If you wish to file an Appeal, it must be done within 60 days of the notice of denial date. There are 2 kinds of appeals: standard and expedited (rush).
A standard appeal request must be in writing and sent to:
Community Health Plan
Attn: Community HealthFirst Appeals
720 Olive Way, Suite 300
Seattle, WA 98101
An expedited appeal can be submitted in writing to the address above, or verbally by calling 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m., 7 days a week. You should file an expedited appeal if your health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision.
You can also fax your appeal request to: 206-613-8983 or deliver it in person to the address listed above.
Depending on the nature and type of your appeal, we will notify you as follows.
Decisions on standard medical appeals - within 30 calendar days from the date we receive your request, but may be extended to 44 calendar days if additional information is necessary.
Decisions on standard appeals for Part D prescription drug coverage determination - within 7 calendar days from the date we receive your request.
Decisions on expedited medical appeals - within 72 hours of the date we receive your request.
Decisions on expedited appeals for Part D prescription drug coverage determination - within 72 hours from the date we receive your request.
Grievances
A grievance is the type of complaint you make if you have a problem with your health care provider or the service we provide to you. For example, you would file a grievance if you have a concern about things such as:
- the quality of the medical care you receive;
- problems with the time you spend waiting on the phone, in a waiting room or in an exam room;
- problems with getting appointments in a timely manner, or having to wait a long time to have your prescription filled;
- problems with our Customer Service;
- disrespectful or rude behavior by pharmacists, providers or other medical staff;
- the cleanliness or condition of pharmacies, providers offices, clinics or hospitals.
There are 2 kinds of Grievance requests: standard and expedited (rush).
A standard grievance request can be submitted verbally by calling 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m, 7 days a week, or in writing and sent to:
Community Health Plan
Attn: Community HealthFirst Grievance Coordinator
720 Olive Way, Suite 300
Seattle, WA 98101
An expedited grievance can be submitted in writing to the address above, or verbally by calling the number above. You should file an expedited grievance if your health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision.
You can also fax your grievance request to: 206-613-8983 or deliver it in person to the address listed above.
Depending on the nature and type of your grievance, we will notify you as follows:
Decisions on standard grievance requests – within 30 calendar days from the date we receive your request, but may be extended if additional information is necessary.
Decisions on Part D prescription drug standard grievance requests– within 72 hours (3 calendar days) from the date we receive your request.
Decisions on expedited grievance requests – within 72 hours (3 calendar days) of the date we receive your request.
Decisions on Part D expedited grievance requests – within 24 hours from the date we receive your request.
Status information for Appeals and Grievances
For a status update on Appeals and Grievances call us 8:00 a.m. to 8:00 p.m., 7 days a week at: 1-800-942-0247 (TTY Relay: 7-1-1)
To obtain an aggregate number of Appeals and Grievances filed with Community HealthFirst, please contact our Customer Service at the number above.
Prescription Drug Policies and Forms for requesting Formulary Exceptions and Coverage Determinations
This applies only to members who have our Medicare Advantage Plans with Pharmacy or our Medicare Advantage Special Needs Plan.
Requesting an exception if your drug is not on the Formulary
If your drug is not listed in the formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Community HealthFirst does not cover your drug, you have two options:
- You can ask Customer Service for a list of similar drugs that are covered by Community HealthFirst. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Community HealthFirst.
- You can ask Community HealthFirst to make an exception and cover your drug. See the following section for information about how to request an exception.
You can ask Community HealthFirst to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Community HealthFirst limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, Community HealthFirst will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Prior Authorization / Medication Exception Request Form.
Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.
Contact information for Prescription Drug Coverage Determination and Exception Requests
Call us at: 1-800-417-8164 or TTY / TDD hearing impaired call 1-800-899-2114
Fax us at: 1-877-837-5922
Send written requests to:
Express Scripts Prior Auth Department – Part D
Community Health Plan of Washington
Mail Route BL0345
6625 West 78th Street
Bloomington, MN 55439