If your medical claim was denied by Medicare and you would like to appeal it, you should contact Medicare and follow its appeal procedures. If the claim was approved by Medicare, but the balance was denied in whole or in part for any reason by HealthChoice, either you, your attorney, or your authorized provider can request that the claim be reviewed by calling Customer Care or by submitting a written request to the HealthChoice Appeals Unit at the address listed below within 180 days of your receipt of a denial.

Please follow the steps below to make sure that your appeal at any level is processed in a timely manner:

• If applicable, send a copy of any letter regarding a decision of your appeal.
• Send a copy of the EOB with any relevant additional information, e.g., benefit documents, medical records, etc., that could help to determine if your claim is covered under the plan.
• Provide a letter summarizing the request for reconsideration that includes your name, the claim or transaction number, HealthChoice member ID number, the name of the patient and their relationship to member. 
• Include Attention: Appeals Unit on all supporting documents. Be certain the member ID appears on each document.
• If you choose to designate an authorized representative, you must provide this designation to us in writing. 
• If your situation is medically urgent, you may request an expedited appeal, which is generally conducted within 72 hours. If you believe your situation is urgent, follow the instructions above for filing an internal appeal and also call Customer Care to request a simultaneous external review.

Your HealthChoice plan’s internal appeals process includes two internal review levels. If you are not satisfied with the final internal review determination due to denial of payment, coverage or service requested, you may be able to ask for an independent, external review of our decision by either an independent review organization or a grievance panel. The entity that performs the external review depends on the nature of your appeal. 

When considering complaints by insured members, the three-member grievance panel shall determine by a preponderance of the evidence whether EGID has followed its statutes, rules, plan documents, policies and internal procedures. The grievance panel shall not expand upon or override any EGID statutes, rules, plan documents, policies and internal procedures.

In order to request access to and copies of all documents, records and other information about your claim, free of charge, or to find out how to start an external review, contact Customer Care at 800-323-4314. TYY user call 711.