The member will be notified within five business days that the complaint has been received. Expedited complaints concerning emergencies or denial of continued hospitalization will be resolved within one (1) business day from receipt of the complaint, or earlier, depending on the medical immediacy of the case. The member will receive a letter with the resolution to the member complaint within three (3) business days.

Members submitting non-expedited complaints will receive a letter with the resolution within thirty (30) calendar days of receipt of the complaint. If the member is not satisfied with the complaint resolution, within (30) days, the member can request an appeal of the complaint resolution. In response to the member complaint appeal, a complaint appeal panel including Ambetter staff, provider(s) and member(s) will be held at a site where the member normally receives healthcare or at another site agreed to by the complainant, upon request. A hearing packet will be sent to the member five (5) days before the appeal panel hearing is held. The member may attend the hearing, have someone represent the member at the hearing, or have a representative attend the hearing with the member. The panel will make a recommendation for the final decision on the member complaint, and Ambetter’s final decision will be provided to the member within thirty (30) days of the member’s complaint appeal request.

The member may also file a complaint with the Texas Department of Insurance (TDI). There are several ways to file a complaint with TDI:

• Visit www.tdi.texas.gov and fill out a complaint form.
• Send an email to ConsumerProtection@tdi.texas.gov.
• Mail the member complaint to:
  Texas Department of Insurance
  Consumer Protection, MC: GC-CCO
  P.O. Box 12030
  Austin, TX 78711-2030

Ambetter will never retaliate against the member because the member filed a complaint, or appealed the decision. Similarly, Ambetter will never retaliate against a physician or provider because the provider has, on the member’s behalf, filed a complaint or appealed a decision.

Member Appeals

The member can request an appeal within one hundred and eighty (180) calendar days of receipt of a medical necessity denial of medical or behavioral health services.

Ambetter will send the member a decision regarding the member’s appeal:

• Expedited – Within one (1) working day for life threatening, urgent or inpatient services
• Standard – Within thirty (30) days

The appeal decision will be made by a physician who has not previously reviewed the case nor is supervised by a physician who has reviewed the case before.

If the member appeal is denied, the member also has the right to request an External Review.

Expedited Appeals

The member has the right to request an expedited appeal if the denial was for emergency care or for a continued hospital stay. We will process the expedited appeal based on the member’s medical condition, procedure or treatment under review. The answer will be completed within one (1) working day or seventy-two (72) hours from the date all needed information is received.

Urgent Appeals

The member can also request an expedited appeal for an urgent care denial. The member can do this if the member thinks the denial could seriously hurt the member’s life or health, or if the member’s Provider thinks that this denial will result in severe pain without the requested care or treatment provided. The decision regarding the member’s appeal for urgent care will be issued within seventy-two (72) hours of the member’s request.

Ambetter must agree with the member’s request that waiting thirty (30) days for a standard appeal could put the member’s life or health in danger. If we do not agree, we will let the member know. The member’s request would then go through the regular process. The member will get a response in thirty (30) days.

Continuing Services

To continue services:

• The member must request an appeal by the latter of: 1) Ten (10) days after the date of the original denial letter; or 2) the day the appealed service will be reduced or ended.
• The member must state in the member request that the member wants to continue services.
• The denied services must have been previously authorized.
• The time period covered by the original authorization must not have ended.

If the above are met, the services will continue until any of the following happen:

• The member cancels the appeal.
• The member’s appeal is denied.
• The appeal decision has been rendered as denied.

If the member’s appeal is not approved, the member may be financially responsible for the continued services.

External Review Process

Getting an External Review is a process that allows members to have their concerns reviewed by a third party. If we have denied an appeal for a service the member or provider has requested, the member can submit a request for External Review, and independent reviewers will look at the case. Members must complete the appeal process with Ambetter before they can submit a request for External review.

Send requests for External Review directly to MAXIMUS at:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Fax number: 1-888-866-6190

Members can view the Major Medical Expense Policy for full complaint and appeal procedures and processes, including specific filing details and timeframes. Members can access the Major Medical Expense Policy in their online member account.