Disputed Claims Procedure
If your medical, dental or pharmacy claim is denied in whole or in part for any reason, either you or your authorized representative can request that the claim be reviewed by calling the claims administrator, or by submitting a written request to the HealthChoice Appeals Unit at the address listed below within 180 days of your receipt of a denial.
HealthChoice Appeals Unit
P.O. Box 3897
Little Rock, AR 72203
Please follow the steps below to make sure that your appeal at any level is processed in a timely manner:
- If applicable, send a copy of any letter regarding a decision of your appeal.
- Send a copy of the EOB with any relevant additional information (e.g., benefit documents, medical records, etc.) that could help to determine if your claim is covered under the plan.
- Provide a letter summarizing the request for reconsideration that includes your name, the claim or transaction number(s), HealthChoice member ID number, the name of the patient and their relationship to member.
- Include "Attention: Appeals Unit" on all supporting documents. Be certain the member ID appears on each document.
- If you choose to designate an authorized representative, you must provide this designation to us in writing.
- If your situation is medically urgent, you may request an expedited appeal which will generally be conducted within 72 hours. If you believe your situation is urgent, follow the instructions above for filing an internal appeal and also call Customer Care to request a simultaneous external review.
Your HealthChoice plan’s internal appeals process includes two internal review levels. If you are not satisfied with the final internal review determination due to denial of payment, coverage, or service requested, you may be able to ask for an independent, external review of our decision by either an independent review organization or a grievance panel. The entity that performs the external review depends on the nature of your appeal.
When considering complaints by insured members, the three-member grievance panel shall determine by a preponderance of the evidence whether EGID has followed its statutes, rules, plan documents, policies and internal procedures. The grievance panel shall not expand upon or override any EGID statutes, rules, plan documents, policies and internal procedures.
In order to request access to and copies of all documents, records and other information about your claim, free of charge, or to find out how to start an external review, contact customer care at 800-323-4314 or TTY 711.