Filing a grievance (complaint) or appeal
- Grievances are complaints.
- An appeal is a request to review a denied service or referral.
You have the right to file a grievance or appeal a decision. Community Health Plan of Washington (CHPW) takes your concerns seriously and consider them opportunities to improve member service.
You can file a grievance with CHPW Customer Service if you are not happy with the way you were treated, the quality of care or services you received, your difficulty getting care, or billing issues.
To file a grievance, contact:
Community Health Plan of Washington
Attention: Customer Service
1111 Third Avenue, Suite 400
Seattle, WA 98101
Here’s what you can expect from us when you file:
✓ Community Health Plan of Washington (CHPW) 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.
If a service was denied, reduced, or ended early, you can appeal that decision. Appeal has four possible steps:
- CHPW appeal
- State hearing
- Independent review
- 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 (denying, reducing, or ending coverage), you may need to pay for services you received during the appeal process.1. Community Health Plan of Washington appeal
You have 60 calendar days after the date of CHPW’s denial letter to ask for an appeal.
You or your representative may request an appeal and/or submit information about your case over the phone, in person, or in writing. You may also fax the information to 206-613-8983. Within 72 hours, we will let you know in writing that we got your appeal.
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. CHPW does not cover any fees or payments to your representatives.
Before or during the appeal, you or your representative may look at your file, medical records, or other documents considered in the appeal. Here’s what you can expect from us during the appeal process:
- 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.
- We provide the Member Appeal Form Online: Download the CHPW Member Appeal Form.
- CHPW can help you file your appeal. Call Customer Service to get started.
If you disagree with CHPW’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 state 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.
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 do not agree with the decision from the state hearing, you have two options:
- You can ask for an independent review within 21 calendar days of the hearing decision.
- You can ask for a final review of your case by the HCA Board of Appeals review judge. (Go to step 4 to learn how.)
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.
Call CHPW for help preparing for your independent review. Any extra information you want us to look at must be given to us within five days of asking for the review.
CHPW will let you know the outcome.
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 (or state hearing, if you didn’t ask for an IRO review). The decision of the HCA Board of Appeals is final.
To ask for this review, contact:
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.
You can get a second opinion about your health care or condition at any time. Call CHPW to learn how.
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:
Consumer Protection Division
Life and Health Section
P.O. Box 40256
Olympia, WA 98504-0256
Insurance Consumer Hotline: 1-800-562-6900