Appeals & Grievances

If your complaint is about a service you or a provider feels you need but we will not cover, you can ask us to review your request again.  This is called an appeal.

If you want to file an appeal you have to file it within 90 days for a Level I Appeal, from the date that you received the letter saying that we would not cover the service you wanted; and 15 days for a Level II Appeal, from the date on the Level I Appeal outcome letter.

You may file your appeal in writing.  We have a simple form you can use to file your appeal.  Please call Member Services at 1-410-779-9369 or 1-800-730-8530 to get one. We will mail or fax the appeal form to you and provide assistance if you need help completing it.  This form can also be found on our website at www.carefirstchpmd.com.

Once you complete the form, you should mail it to:

CareFirst Community Health Plan Maryland (CareFirst CHPMD)

Attention: Appeals & Grievance Department

PO Box 915

Owings Mills, MD 21117

Your doctor can also file an appeal for you if you sign a form giving him or her permission.  Other people can also help you file an appeal, like a family member or a lawyer, when they file a form (i.e. an Appointment of Representative Form) allowing them to file on your behalf.

When you file an appeal, be sure to let us know any new information that you have that will help us make our decision. 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.

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.
• Make a decision about your appeal within 30 days.

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.  A CareFirst CHPMD Medical Director will review the request and determine if your issue is life threatening.  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 1-800-730-8530 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.  Examples of grievances would be, not being able to find a doctor, trouble getting an appointment, or not being treated fairly by someone who works at CareFirst CHPMD or at your doctor’s office.

If your grievance is:

• About an urgent medical problem you are having, it will be solved within 24 hours.
• About a medical problem but it is not urgent, it will be solved within 5 days.
• Not about a medical problem, it will be solved within 30 days.

If you would like a copy of our official complaint procedure, or if you need help filing a complaint, please call CareFirst CHPMD at 1-410-779-9369 or 1-800-730-8530.  You may also submit your grievance in writing.  We have a simple form you can use to submit your grievance.  Please call Member Services at 1-410-779-9369 or 1-800-730-8530 to get one.  We will mail or fax the appeal form to you and provide assistance if you need help completing it.  

Once you complete the form, you should mail it to:

CareFirst Community Health Plan Maryland (CareFirst CHPMD)

Attention: Appeals & Grievance Department

PO Box 915

Owings Mills, MD 21117