Appeals, Organizational Determinations, Coverage Determinations, Grievances

An organization determination is a decision we make about whether items or services are covered or how much you have to pay for covered items or services. Chapter 9 in our Evidence of Coverage explains how to ask us for a coverage decision.

A Coverage Determination is a decision we make about what drugs are covered and how much you will have to pay for those drugs.

These types of decisions are sometimes called “Coverage Decisions”.  Please refer to Chapter 9 in our Evidence of Coverage which provides detailed information on how you can file an organization determination for medical services and coverage determinations for prescription drugs.

• 2025 Evidence of Coverage – Texas Independence Health Plan (PBP-001)
• 2025 Evidence of Coverage – Texas Independence Community Plan (PBP-002)
• 2025 Evidence of Coverage – Texas Independence Health Plan (PBP-001) (Spanish)
• 2025 Evidence of Coverage – Texas Independence Community Plan (PBP-002) (Spanish)

• CALL:  Please contact our Member Services number at 833-471-8447 for additional information. (TTY users should call 833-414-8447). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.
• WRITE: 1908 N. Laurent Street Suite 250 Victoria, TX 77901
• FAX: 877-235-1650

• CALL: Please contact our Member Services Department at our Pharmacy Benefit Manager at 1-866-213-1594 for additional information.  (TTY users should call 711)  Our pharmacy Member Services is open 24 hours a day, seven (7) days a week.
• WRITE:
  • MedImpact
    Attn: Clinical Services
    10181 Scripps Gateway Ct
    San Diego, CA 92131
• FAX: 1-877-503-7231

An appeal is something you request if you disagree with our decision to deny a request for coverage of health care services/prescription drugs, payment of services or for drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are already receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive. Chapter 9 in our Evidence of Coverage explains appeals, including the process involved in making an appeal.

• 2025 Evidence of Coverage – Texas Independence Health Plan (PBP-001)
• 2025 Evidence of Coverage – Texas Independence Community Plan (PBP-002)
• 2025 Evidence of Coverage – Texas Independence Health Plan (PBP-001) (Spanish)
• 2025 Evidence of Coverage – Texas Independence Community Plan (PBP-002) (Spanish)

You or your appointed representative may request an appeal. You may appoint someone to act on your behalf and serve as your representative for an appeal.  You and your appointment representative must sign the Appointment of Representative Form CMS 1696 or equivalent written notice and include this form with your appeal.  The appointment is valid for one year unless revoked.  A copy of this form must be included with any future appeals.

Your doctor can request an appeal for you. For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf.   For Part D prescription drugs, your doctor or the prescriber can request a coverage decision or a Level 1 or Level 2 appeal on your behalf.

If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 in our Evidence of Coverage. It provides the details on how to make an appeal if you want us to change our decision. Chapter 9 also explains how to make a complaint around quality of care, waiting times, and other concerns.

• 2025 Evidence of Coverage – Texas Independence Health Plan (PBP-001)
• 2025 Evidence of Coverage – Texas Independence Community Plan (PBP-002)
• 2025 Evidence of Coverage – Texas Independence Health Plan (PBP-001) (Spanish)
• 2025 Evidence of Coverage – Texas Independence Community Plan (PBP-002) (Spanish)

You must make your appeal request within 60 calendar days from the date indicated on the written notice we sent notifying you of our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include but is not limited to a serious illness that prevented you from contacting us. Another example would be if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

If your health requires it, ask for a “fast appeal” You or your representative must contact us at 833-471-8447 (TTY 833-414-8447) or in writing to: THIP 1908 N. Laurent St., Ste. 250, Victoria, TX 77901 or fax to 833-605-4044

If your health requires it, ask for a “fast appeal”, your doctor must contact us at 833-471-8447 (TTY 833–414-8447) or in writing to: TIHP 1908 N. Laurent St., Ste. 250, Victoria, TX 77901

If you are asking for a “standard appeal”, make your standard appeal in writing by submitting a request to TIHP 1908 N. Laurent St., Ste. 250, Victoria, TX 77901

If you are asking for a “fast appeal” you can call TIHP at 866-213-1594.

If you’re asking for a “standard appeal” make your standard appeal by calling 866-213-1594 or in writing by filling out the Request for Redetermination of Medicare Prescription Drug Denial form (links below) and fax it to 877-503-7231 or mail it to:

MedImpact
Attn: Appeals Department
10181 Scripps Gateway Ct
San Diego, CA 92131

• Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
• Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form (Spanish)

 

OR go to our Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)

If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. If you had a “fast appeal” at Level 1 you will also have a “fast appeal” at Level 2. If you had a “standard appeal” at Level 1, you will also have a “standard appeal” at Level 2.

If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.

A grievance is a type of complaint you make about us or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

The complaint must be made within 60 days after you had the problem you would like to tell us about.

Call our Member Services number at 833-471-8447 for additional information. (TTY users should call 833-414-8447). Hours are 8:00 A.M. to 8:00 P.M., seven days a week from October 1 through March 31; 8:00 A.M. to 8:00 P.M. Monday to Friday from April 1 through September 30.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and fax it to 833-605-4044 or mail it to:

Texas Independence Health Plan
1908 N. Laurent St., Ste. 250
Victoria, TX 77901

Call our Member Services number at 866-213-1594 for additional information. (TTY users should call 711). Hours are 24 hours a day, 7 days a week.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and fax it to 833-605-4044 or mail it to:

Texas Independence Health Plan
1908 N. Laurent Street
Suite 250
Victoria, TX 77901

If you are making a complaint because we denied your request for a “fast appeal”, we will automatically give you a “fast complaint.” If you have a “fast complaint,” it means we give you an answer within 24 hours.