How to File an Appeal

Appeals

If you receive a denial letter and do not like the choice we made, you can file an appeal. An appeal is a request to review an action or denial. An action is any denial that is:

  • Limited
  • Reduced
  • Suspended
  • Terminated, or
  • Payment is denied

 

Filing an Appeal

All appeals must be filed in 60 days from the day of the denial. If you call, you may be asked to send more information in writing. To file your appeal, you can:

  • Call Member Services
  • Write a letter
  • Fill out the Appeal Request form (Coming Soon)

 

Mail the letter  to:

Passport Health Plan
Attention: Member Grievance and Appeals

5100 Commerce Crossings Drive

Louisville, KY 40229

(800) 578-0603

 

If you need a copy of the Appeal Request Form (Coming Soon) you can call Member Services or download and print a copy. We can help you write your appeal. Your request needs:

  • Your first and last name
  • Your Passport ID number. It is on the front of your Member ID Card
  • Your address and telephone number
  • Explain the problem

 

We try to solve your appeal right away. Your appeal is looked at by the Complaint, Grievance and Appeals Department. A letter is mailed to you in 10 days. This letter lets you know we have received your appeal and we will tell you when we expect to resolve your appeal. The reviewer will note and take care of your appeal. The reviewer will work with the right departments to solve your appeal. For standard appeals, we will mail our decision in 30 days from the day we received it or as expeditiously as your health requires. You or we can request an additional 14 days to resolve your appeal. We will write you and tell you that we have requested an additional 14 days and the reason for requesting the additional time. For expedited appeals, we will mail our decision in 72 hours from the day we receive it.

In order to be fair, cases will not be looked at by the same person that made the first decision. All appeals about medical services are reviewed by our medical staff.

 

Expedited or Rushed Appeals

An expedited or a rushed appeal is when waiting for a regular appeal may risk your life or health. All rushed appeals will be solved in 72 hours or as quickly as your health condition requires but no more than 72 hours from the date of the request for a rushed appeal.

 

Filing a Rushed Appeal

You, your doctor or someone else, with your approval in writing, may call or write to ask for an appeal to be rushed. We can help you with this. Passport will decide if your appeal meets a rushed review.

You, your Provider or an Authorized Representative may file a fast appeal within 10 calendar days of the date the adverse benefit determination was received. We will give you a verbal decision on a fast appeal within 72 hours. We will follow up in writing in 2 days of receiving it.

 

Continuing benefits during appeal process

If you would like to go on with your benefits while you are appealing you must:

  • Let us know in (10) days from the date on the denial letter.
  • Let us know in (10) days after the effective date of the action, whichever is later.

 

The appeal must be about an action that was denied. An action is any denial that is:

  • Limited
  • Reduced
  • Suspended
  • Terminated of a treatment that was approved before

 

The service must have been asked for by an approved doctor

  • The approval cannot have ended.
  • If you request an extension of benefits.

 

If we decide to go on with your benefits, your benefits will go on until:

  • You withdraw the appeal.
  • Ten days have passed from the date of the denial and you have not asked for a Medicaid Fair Hearing.
  • The Medicaid Fair hearing makes a decision not in your favor.
  • The authorization for the benefits has ended or the limits are met.

 

If you asked to go on with your benefits and the decision is not in your favor you may have to pay for the services that were given to you. Mail a letter, call or fax the request to:

Passport Health Plan
Attention: Member Grievance and Appeals

5100 Commerce Crossings Drive

Louisville, KY 40229

(800) 578-0603