Child Health Plan Plus (CHP+) Complaints and Appeals

After you file your complaint, DHMP will send you a letter within two working days to let you know that your complaint was received. DHMP will look into the details of your complaint and will decide how to handle it (in other words, DHMP will try to resolve your complaint). The DHMP staff members who make decisions on your complaint will not be the same people who you are filing your complaint about. If you file a complaint because you feel you got poor medical care or because DHMP denied your expedited appeal request, a DHMP staff member with appropriate medical training will look into your complaint.

DHMP will make a decision on your complaint and send you written notice as soon as your health condition requires, but no later than 15 working days from the day you file your complaint. The written notice will explain the results of DHMP’s decision on your complaint and the date DHMP made that decision.

You or DHMP can extend the timeframe that DHMP has to make a decision on your complaint. If you ask for more days or if DHMP believes that more facts are needed to make a decision on your complaint, DHMP may add 14 more calendar days. DHMP will only extend this timeframe if it is in your best interest. If DHMP extends the timeframe to decide on your complaint and you did not ask for the extension, DHMP will send you written notice of the reason for the delay.

DHMP will help you file a complaint. If you need help filling out any forms or taking any of the steps to file a complaint, including using an interpreter or TTY services, please call Complaints and Appeals at 303-602-2261.

If you are still unhappy with how DHMP handles your complaint, you can go to the State of Colorado. The State of Colorado's ruling is final. You can call them at 1-800-221-3943 (no charge) or you can write them at:

Department of Health Care Policy & Financing
Attn: CHP+ Contract Manager
1570 Grant Street
Denver, CO 80203-1714

This is a letter that DHMP sends you if DHMP takes any action to any part of your DHMP services. An action may include:

• When DHMP denies or limits a type or level of service you ask for
• When DHMP reduces, suspends, or stops authorizing a service that you have been getting
• When DHMP denies full or partial payment or your services
• When DHMP does not give you a service in a timely manner
• When DHMP does not resolve your appeal or complaint within the required timeframes

A Notice of Adverse Benefit Determination Letter includes:

• The action that DHMP plans to take
• The reason for the action
• Your right to appeal this action
• The date when you need to appeal by
• Your right to ask for a State Fair Hearing
• How to ask for a State Fair Hearing
• When you can ask to speed up the appeal process
• How to keep getting services while the appeal or State Fair Hearing is being decided
• When you might have to pay for those services you got while a final ruling was pending

DHMP must let you know about an action before the action happens. If DHMP plans to stop paying for or reducing any services you have been getting, it has to send you a Notice of Adverse Benefit Determination Letter 10 calendar days before the date it stops paying for or reducing services. DHMP can shorten the timeframe to five calendar days if:

• There is fraud
• The Member has passed away
• The Member is institutionalized
• The Member’s whereabouts are unknown and there is no forwarding address
• The Member has moved out of state or outside metropolitan Denver or has become eligible for benefits outside of state
• The Member’s doctor orders a change in the level of care
• Pre-admission screening of the Social Security Act
• The Member’s safety or health is endangered
• The medical care is urgently needed
• You must be transferred to another facility
• DHMP gets a letter from you saying that you no longer want services (this letter must have information that requires that your services with DHMP end)

You have sixty (60) calendar days to file an appeal after you get a Notice of Adverse Benefit Determination Letter for a new service that you are not yet getting.

To appeal an action that will stop, suspend or cut back on services you are already getting, you have to file the appeal within 10 calendar days after the date the Notice of Adverse Benefit Determination Letter was sent out, or on or before the intended effective date of DHMP's action.

To appeal an action you may:

• Call DHMP Complaints and Appeals at 303-602-2261, TTY users should call 711. If you appeal an action verbally, you must also send in a written appeal (unless you have requested an expedited appeal)
• Fill out the Complaint and Appeal Form and fax to 303-602-2078 or mail to:

  DHMP Complaints and Appeals
  777 Bannock St., MC6000
  Denver, CO 80204

If your life or health is in danger and you need DHMP to make a decision on your appeal right away, you can call DHMP Complaints and Appeals Department at 303-602-2261 and request an expedited appeal. If DHMP approves your request for an expedited appeal, DHMP will make a decision on your appeal as quickly as your health condition requires, but no more than 72 hours from the date of your request. If DHMP denies your request for an expedited appeal, DHMP will call you to let you know your request was denied. DHMP will also send you a letter within two calendar days of your request to let you know that your request was denied. The letter will let you know that you have the right to file a complaint if you are unhappy with DHMP’s decision. You will get a written version of your appeal with this denial letter (if you filed your appeal verbally) that you must sign and send back to DHMP. DHMP will then review your appeal in the standard timeframe explained in the next section.

After you file an appeal, DHMP will send you a letter within two working days (unless you file an expedited appeal) to let you know your appeal was received. DHMP will look into the details of your appeal and will decide to either accept your appeal (overturn DHMP’s action) or deny your appeal (uphold DHMP’s action). The DHMP staff members who make decisions on your appeal will not be the same people who made the original decision.

If you appeal an action that uses the reason “lack of medical necessity,” a DHMP staff member will review with a medical professional to make a decision on your appeal. At any time during the appeal process, you or your DPR may provide DHMP (in person or in writing) any evidence or other information to help your case. Please note that if your appeal is expedited, you have a shorter amount of time to give DHMP this information.

You or your DPR may also look at your case file before and during the appeal process. Your case file includes your medical records and any other information that DHMP is using to decide on your appeal; this information will be provided free of charge and sufficiently in advance of the appeal resolution timeframe. The request to review your case file is free of charge.

For standard appeals, DHMP will make a decision and send you written notice of the decision no later than 10 working days from the date you file your standard appeal. For expedited appeals, DHMP will make a decision and send you written notice of the decision within 72 hours from the date you file your expedited appeal. DHMP will also try to notify you of the decision over the phone for expedited appeals. The written notice will tell you the outcome of DHMP’s decision on your appeal and the date that it was completed. If the outcome is not in your favor, the written notice will also give you information on your right to request a State Fair Hearing and how to request one.

You or DHMP can extend the timeframe for DHMP to make a decision on your expedited or standard appeal. If you ask for more days or if DHMP believes that more facts are needed to make a decision on your appeal, DHMP may add 14 more calendar days. DHMP will only extend this timeframe if it is in your best interest. If DHMP extends the timeframe to decide on your appeal and you did not ask for the extension, DHMP will send you written notice of the reason for the delay. This written notice will also explain that you have the right to file a complaint if you do not agree with DHMP’s decision to extend the timeframe. During the extended timeframe, DHMP will make a decision and send you written notice of the decision no later than 10 working days from the date the timeframe was extended.

To get help filing your appeal, you can:

• Call Complaints and Appeals at 303-602-2261, TTY call 711
• Call the Health First Colorado CHP+ Ombudsman at 303-830-3560 or 1-877-435-7123

You will not lose your Health First Colorado benefits if you appeal an action. It is the law!

If you are unhappy with an action that DHMP takes, you MUST go through the appeal process explained above. You can request a formal hearing up to 120 calendar days after receiving an appeal decision that you do not agree with. This means you or your DPR have the choice to ask for an Administrative Law Judge to review an action taken by DHMP. Your provider can also ask for a review if you make them your DPR. This review is called a State Fair Hearing. You may request a State Fair Hearing when:

• Services you seek are denied or the ruling to approve services is not acted upon in a timely manner
• You believe the action taken is wrong

To request a State Fair Hearing, you, your DPR, or your subscribing provider must send a letter to the Office of Administrative Courts. The letter should contain all of the following:

• Your name, address and CHP+ ID number (a letter and 6 numbers)
• The action, denial or failure to act quickly on which the request appeal is based
• The reason for appealing the action, denial or failure to act quickly

At the hearing, you can represent yourself or use a provider, legal guide, a relative, a friend, or other spokesperson. You or your representative will have a chance to present evidence to the Administrative Law Judge to support your case. You or your representative may also ask for records that pertain to your appeal. If you would like someone else to represent you, you must fill out the State Fair Hearing written consent form called Representative Authorization. This form is on the State of Colorado’s website under the Department of Personnel and Administration, Office of Administrative Courts. The person you put on the form is called your authorized representative. You have to request a State Fair Hearing within 120 calendar days from the notice of action to:

Office of Administrative Courts
1525 Sherman St., 4th floor
Denver, CO 80203

 DHMP will provide the disputed services as promptly and as expeditiously as your health condition requires, but no later than 72 hours from the date it receives notice reversing the determination.

If you need help requesting a State Fair Hearing, DHMP will help you. Just call Complaints and Appeals at 303-602-2261 and ask for help. You can also call the Office of Administrative Courts at 303-866-2000. Any ruling made in a State Fair Hearing is final.

The continuation of benefits during appeals and State Fair Hearings does not apply to CHP+.