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State Members

Appeals

Administrative

Administrative appeals involve issues regarding MCHCP eligibility, plan effective dates, premium payments and plan choices.

Administrative appeals must be submitted in writing within 180 days of the date of the notice of administrative decision or written denial of the request. All administrative appeals should be addressed to:

Missouri Consolidated Health Care Plan
Attn: Appeals
PO Box 104355
Jefferson City, MO 65110-4355
Fax: 866-346-8785
Log into myMCHCP and send a secure message in Messages

Medical

An appeal is when a member requests the medical plan to reconsider its decision to deny payment of a claim.

Internal Appeal

There are two levels of internal appeal. A first level appeal must be submitted in writing to the medical plan within 180 days of the date of the original notice. If a second level appeal is needed, it must be submitted in writing to the medical plan within 60 days of the date of the first level decision. In most cases, the member must exhaust both levels of appeal before moving to an external review.

Internal appeals will be reviewed by someone who was not involved in the previous decision. The review will include a qualified medical professional if a medical judgement is involved.

A written response will be issued within 30 days for post-service claims and 15 days for pre-service claims from the date the medical plan received the appeal request. If more time for review is required for reasons beyond the plan's control, the plan must notify the member within 15 days of the appeal request. The notification must explain the reason for the delay and may request additional information.

An expedited appeal may be requested by telephone or fax to the medical plan when a decision is related to a pre-service claim for urgent care. The medical plan must respond verbally within 72 hours of receiving a request for an expedited review. Written confirmation of the decision will be provided within three working days of notification of the determination.

UMR and Aetna appeals addresses

External Review

After completion of the internal appeals process for medical or pharmacy services, an external review is available for covered medical and pharmacy benefits through the U.S. Office of Personnel Management (OPM) and the U.S. Department of Health & Human Services (HHS).

Members may file a written request for external review within four months of receiving a final internal adverse benefit determination. A decision will be made within 45 days of the request.

Members may file an expedited review if the standard review time frame would seriously jeopardize their life or health, or the ability to regain maximum function, or if the final internal adverse benefit determination involves admission, availability of care, continued stay, or an item or service for which the member received services but has not been discharged from the facility.

Send review requests to:

MAXIMUS Federal Services, Inc.
MAXIMUS Federal Services
3750 Monroe Ave., Suite 705
Pittsford, NY 14534
Fax: 888-866-6190
Website: www.externalappeal.com

Contact MAXIMUS Federal Services at 888-866-6205 with questions or concerns during the external review process.

Pharmacy

Internal Appeal

An appeal of a decision concerning a pharmacy service must be submitted in writing within 180 days of the date on the original notice. Include the following, if applicable:

  • The date you attempted to fill the prescription;
  • The prescribing physician's name;
  • The drug name and quantity;
  • The cost of the prescription;
  • The reason you believe the claim should be paid;
  • Any additional information or documentation you think will be helpful.

An expedited appeal may be requested by telephone or fax when a decision is related to a pre-service claim for urgent care. Express Scripts must respond verbally within 72 hours of receiving a request for an expedited review. Written confirmation of the decision will be provided within three working days of notification of the determination.

Express Scripts appeals address

Your appeal will be reviewed by someone who was not involved in the original decision. A qualified medical professional will be consulted if a medical judgment is involved. ESI must respond in writing within 60 days for post-service claims and within 30 days for pre-service claims from the date they receive the appeal request.

External Review

After completion of the internal appeals process for medical or pharmacy services, an external review is available for covered medical and pharmacy benefits through the U.S. Office of Personnel Management (OPM) and the U.S. Department of Health & Human Services (HHS).

Members may file a written request for external review within four months of receiving a final internal adverse benefit determination. A decision will be made within 45 days of the request.

Members may file an expedited review if the standard review time frame would seriously jeopardize their life or health, or the ability to regain maximum function, or if the final internal adverse benefit determination involves admission, availability of care, continued stay, or an item or service for which the member received services but has not been discharged from the facility.

Send review requests to:

MAXIMUS Federal Services, Inc.
MAXIMUS Federal Services
3750 Monroe Ave., Suite 705
Pittsford, NY 14534
Fax: 888-866-6190
Website: www.externalappeal.com

Contact MAXIMUS Federal Services at 888-866-6205 with questions or concerns during the external review process.

Dental and Vision

Members should contact the dental or vision plan for information concerning their appeal rights.

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