Filing a Grievance or Appeal
We take your concerns seriously and consider them opportunities to improve member care and service. You have the right to file a grievance or appeal a decision.
Grievances are complaints. You can file a grievance with your health plan if you are not happy with the way you were treated, the quality of care or services you received, you have problems getting care, or billing issues. If you need help filing a grievance, call 1-800-440-1561, or if you have a machine for telephone calls because you do not hear well, please call TTD/TTY: 711.
To file a grievance, contact:
Community Health Plan of Washington
Attention: Customer Service
1111 Third Avenue, Suite 400
Seattle, WA 98101
Phone: 1-800-440-1561 (TTY Relay: Dial 711)
Community Health Plan of Washington will keep your grievance private. We will let you know we received your grievance within two business days. We will try to take care of your grievance right away. We will resolve your grievance within 45 days and tell you how it was resolved.
An appeal is a request to review a denied service or referral. You can appeal our decision if a service was denied, reduced, or ended early. Below are the steps in the appeal process:
STEP 1: Community Health Plan of Washington Appeal
STEP 2: State Hearing
STEP 3: Independent Review
STEP 4: Health Care Authority (HCA) Board of Appeals Review Judge
Continuation of Services During the Appeal Process
If you want to keep getting previously approved services while we review your appeal, you must tell us within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our action, you may need to pay for services you received during the appeal process.
STEP 1 – Community Health Plan of Washington Appeal
You have 180 calendar days after the date of Community Health Plan of Washington’s denial letter to ask for an appeal. You or your representative may request an appeal or may submit information about your case over the phone, in person, or in writing. You may fax the information to 206-613-8983. Within 72 hours, we will let you know in writing that we got your appeal. Community Health Plan of Washington can help you file your appeal. If you need help filing an appeal, call Customer Service.
You may choose someone, including a lawyer or provider, to represent you and act on your behalf. You must sign a consent form allowing this person to represent you. Community Health Plan of Washington does not cover any fees or payments to your representatives. That is your responsibility.
Before or during the appeal, you or your representative may look at your file, medical records, or other documents considered in the appeal. If you want copies of the guidelines we used to make our decision, we can give them to you at no charge. We will keep your appeal private. We will send you our decision in writing within 14 calendar days, unless we tell you we need more time. Our review will not take longer than 28 calendar days, unless you give us written consent.
STEP 2 – State Hearing:
If you disagree with Community Health Plan of Washington’s appeal decision, you can ask for a State Hearing. You must complete Community Health Plan of Washington’s appeal process before you can have a hearing. You must ask for a hearing within 120 calendar days of the date on the appeal decision letter. When you ask for a hearing, you need to say what service was denied, when it was denied, and the reason it was denied. Your provider may not ask for a Hearing on your behalf.
To ask for a State Hearing:
- Contact the Office of Administrative Hearings directly at 1-800-583-8271 , or write to them at: P.O. Box 42489, Olympia, Washington, 98504-2489.
You may consult with a lawyer or have another person represent you at the Hearing. If you need help finding a lawyer, check with the nearest Legal Services Office or call the NW Justice CLEAR line at 1-888-201-1014 or visit their website at www.nwjustice.org.
STEP 3 – Independent Review:
If you do not agree with the decision from the State Hearing, you can ask for an independent review within 21 calendar days of the Hearing decision or you may go directly to Step 4. Call Community Health Plan of Washington for help. Any extra information you want us to look at must be given to us within five days of asking for the independent review. If you ask for this review, your case will be sent to an Independent Review Organization (IRO) within three working days. You do not have to pay for this review. Community Health Plan of Washington will let you know the outcome.
STEP 4 – Health Care Authority (HCA) Board of Appeals
You can ask for a final review of your case by the HCA Board of Appeals Review Judge. You must ask for this within 21 calendar days after the IRO decision is mailed. The decision of the HCA Board of Appeals is final.
To ask for this review contact:
HCA Board of Appeals
Phone: (360) 725-0910 or Fax: (360) 507-9018, Toll free: (877) 728-5212
P.O. Box 42700
Olympia, WA 98504-2700
Expedited (faster) Decisions
If you or your provider think waiting for a decision would put your health at risk, you may ask for an expedited (faster) appeal, state hearing, or IRO. Information that you think we need to look at must be given to us quickly. We will review your request and make a fast decision. If we decide your health is not at risk, we will let you know and we will follow the regular timeframe to make our decision.
At any time you can get a second opinion about your health care or condition. Call Community Health Plan of Washington to find out how to get a second opinion.
Washington State Health Insurance Consumer Assistance Program
The Consumer Protection Division in the Washington State Office of the Insurance Commissioner can help you with questions and complaints.
For help, contact:
Consumer Protection Division
Life and Health Section
P.O. Box 40256
Olympia, WA 98504-0256
Phone: Insurance Consumer Hotline: 1-800-562-6900