How to file complaint of grievance carefirst

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We will send you a letter letting you know that we received your appeal within 5 business days of receipt in the company. While your appeal is being reviewed, you can still send or deliver any additional information that you think will help us make our decision. The appeal process may take up to 44 days if you ask for more time to submit information or we need to get additional information from other sources.

We will send you a letter if we need additional information. If your doctor or CareFirst CHPMD feels that your appeal should be reviewed quickly due to the seriousness of your condition, this is called an expedited appeal.

You will receive a decision about your appeal within 72 hours. When you ask for an expedited appeal, you may do so by calling us, or asking us in writing. If we do not feel that your appeal needs to be reviewed quickly, we will try to call you and send you a letter letting you know that your appeal will be reviewed within 30 days.

If your appeal is about a service that was already authorized and you were already receiving, you may be able to keep getting the service while we review your appeal. Contact us at if you would like to keep getting services while your appeal is reviewed.

If you do not win your appeal, you may have to pay for the services that you received while the appeal was being reviewed. Once we complete our review, we will send you a letter letting you know our decision.

If we decide that you should not receive the denied service, that letter will tell you how to file another appeal or ask for a State Fair Hearing. If your complaint is about something other than not receiving a service, this is called a grievance. If you would like a copy of our official complaint procedure, or if you need help filing a complaint, please call CareFirst CHPMD at or You may also submit your grievance in writing.

We have a simple form you can use to submit your grievance. When reviewing your appeal we will: Use doctors who know about the type of illness you have. Not use the same people who denied your request for a service. The resolution letter will contain the rationale for the determination, the credentials of the reviewer involved in the determination, and the opportunity for a second level appeal. The contracted physician resolving the Claim Payment Appeal dispute holds the same specialty or a related specialty as the Appealing Provider.

The provider must notify CareFirst CHPMD of their request for a second level appeal within 15 business days of the date of the letter noting the outcome of the appeal. A meeting between the Chief Executive Officer CareFirst Community Health Plan Maryland or designee, the provider and a provider who was not involved in the case is scheduled. CareFirst CHPMD appoints a new reviewer who was not involved with the initial determination, is not a subordinate of any person involved in the initial appeal determination and is of the same or similar specialty as typically treats the medical condition or performs the procedure.

The selected reviewer receives all documentation used in the initial appeal process for review and any additional information provided for the second level of review. The appellant is notified in writing of the decision. Notification of the Outcome of Appeal When the outcome of the appeal is known, the results and the date of the appeal resolution will be provided in writing to the provider.

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