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Appeals and Grievances

What is an appeal?
An appeal is a special kind of complaint you can make if KelseyCare Advantage refuses to cover something you think should be covered. If you disagree with the plan's initial decision (organizational determination), you, your representative or your treating physician can request an appeal, but you must make your request within 60 days from the date of the organizational determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. An appeal to the plan about an organizational determination is called a plan “reconsideration.” Please refer to your Evidence of Coverage that discusses the 5 levels of appeals. When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor to get more information.

Who can file an appeal?
You, your representative or your treating physician can ask for a standard or fast appeal.  You will get a fast decision if we determine or your physician tells us, that your life or health may be at risk by waiting for a standard decision. If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. If we are using the standard deadlines, we must give you our answer within 30 days for standard service requests and 60 days for payment requests. The time to complete standard service and fast requests may be extended by up to 14 days if, for example, we need more information to make a decision about the case, and the extension is in your best interest.
 
How do you file an appeal?
For standard appeals requests, you or your treating physician must make your request to us in writing.  Your written reconsideration request should include:
  • Your name, address, and your member ID number.   
  • The items or services for which you're asking for a reconsideration and the dates of service. 
  • Your signature. 
  • You should also include any other information that may help your case. 
  • A "fast" or expedited appeal is accepted by us in writing, in person or over the telephone.

What is a grievance (complaint)?

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.
  • Do you believe that someone did not respect to privacy or shared information about you that you feel should be confidential? 
  • Has someone been rude or disrespectful to you? 
  • Do you feel waiting too long on the phone or when getting medical care? 
  • Do you believe we have not given you a notice that we are required to give?
  • If you have asked us to give you a “fast response” for an organizational determination or an appeal, and we have said we will not, you can make a complaint. 
  • If you believe our plan is not meeting deadlines for giving you a organizational determination or an answer to an appeal you have made, you can make a complaint.

You must file a grievance within 60 days from the date of the event that led to the complaint. Grievances are reviewed on an individual basis and we will resolve the grievance as quickly as your health status requires. If you call us with a complaint, we may be able to give you an answer on the same phone call. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. Expedited or fast grievances will be responded to within 24 hours if the grievance is related the plan’s refusal to make a fast coverage organizational determination or reconsideration and you haven’t received the medical care yet.  We will address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint. 

How to contact us when you are making an appeal or a complaint:
1-866-535-8343

Hours of Operation: From October 1 through February 14, hours are 8:00 a.m. to 8:00 p.m., seven days a week. During this time period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system.  From February 15 through September 30, hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. During this time period on Saturdays, Sundays and Federal holidays, calls are handled by our voicemail system. We will return calls the next business day.

TTY:  1-866-302-9336 
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.

FAX:  713-442-9536

WRITE:
KelseyCare Advantage
Attn:  Grievance and Appeals
P.O. Box 841569
Pearland, TX 77584-9832

For information about the total number of grievances, appeals and exceptions filed with KelseyCare Advantage, please contact KelseyCare Advantage using the phone numbers listed above.

You may view or download a printable version of the Evidence of Coverage
for each plan:
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