PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Expedited Appeal can be made verbally or in writing as indicated in the Member Complaint to HMO listed
above. Expedited appeals for emergency care denials and denials of continued hospital stays will be reviewed
by a Medical Director that was not involved in the original denial and is of the same or a similar specialty as
typically manages the medical condition, procedure, or treatment under review. The time frame in which the
appeal is completed will be based on the medical immediacy of the condition, procedure, or treatment, but will
not exceed one (1) working day from the date all information necessary to complete the appeal is received.
If the member or member’s designee asks for an expedited appeal for a denial that does not involve an
emergency, an ongoing hospitalization or services that are already being given they will be notified that the
appeal review cannot be expedited. We will continue to process the appeal within the standard timeframe and
respond to you within 30 days from the time the appeal was received. If the member or member’s designee
does not agree with this decision they can submit a request for an Independent Review Organization as
described below.
Members can also file a complaint to the Texas Department of Insurance by calling 1-800-252-3439 or writing
to:
Texas Department of Insurance
PO Box 149104
Austin, TX 78714-9104
Fax: 512-475-1771
Web: http://www.tdi.state.tx.us
Email: ConsumerProtection@tdi.state.tx.us
Member Adverse Determination Appeal Process to HMO
A member, a person acting on behalf of the member, or the member's doctor or health care provider can appeal
an adverse determination orally or in writing. Any complaint filed concerning dissatisfaction or disagreement
with an adverse determination constitutes an appeal of the adverse determination.
Within five (5) working days from receipt of the appeal, an acknowledgement letter will be sent to the
appealing party. The acknowledgement letter will include: the date of receipt of the appeal; a description of the
appeal procedure and timeframes; a list of the documents, such as new, previously unknown information,
further reasonable documentation related to the case but not previously received or medical records that will
need to be submitted for review during the appeal process. The provider will have five (5) business days to
submit the additional information requested; and a one-page appeal form, if the appeal is oral.
As soon as practical, but in no case later than thirty (30) calendar days of receipt of the appeal, all available
information will be reviewed by a doctor who was not involved in making the initial adverse determination and
a written notice of the appeal determination will be sent to the appealing party.
If the appeal is denied, the written notice to the member, member’s designee, and member’s provider shall
include a clear and concise statement that includes: the clinical basis for the appeal’s denial; the specialty of the
doctor making the denial; the right of the appealing party to seek review of the denial by an independent review
organization and the procedures for obtaining that review; the right to an immediate appeal to an independent
review organization in circumstances involving a condition that is life-threatening to the member; the right of
the health care provider to set forth in writing within ten (10) working days of the appeal denial good cause for
having a particular type of specialty provider review the case.
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