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Customer Service / 24-Hr Nurse Advice Line
Customer Service Numbers
TX (888) 371-1249
TX TTY – (866) 489-9042
En Español

We hope you are happy with your Allegian Choice health plan, however, if you have a problem with any Allegian Choice service, we want to help fix it. You can call any of the following toll-free numbers for help:

  • Call Allegian Choice toll-free at (888) 371-1249
  • Deaf or hard of hearing members may call our toll-free TTY number at (866) 489-9042 to access the Arizona Relay System.
  • You may also send us your problem or complaint in writing by mail. Our address is: 

Allegian Choice Member Services
Attention: Grievances and Appeals
7878 N. 16th Street
Suite 105
Phoenix, AZ 85020

APPEALS

 Definitions
The capitalized terms used in this appeals section have the following definitions:

Adverse Benefit Determination

  • A denial of a request for service or a failure to provide or make payment in whole or in part for a benefit;
  • Any reduction or termination of a benefit, or any other coverage determination that an admission, availability of care, continued stay, or other health care service does not meet Allegian Choices’ requirements for Medical Necessity, appropriateness, health care setting, or level of care or effectiveness; or
  • Based in whole or in part on medical judgment, includes the failure to cover services because they are determined to be experimental, investigational, cosmetic, not Medically Necessary or inappropriate.
  • A decision by Allegian Choice to deny coverage based upon an initial eligibility determination.

An Adverse Benefit Determination is also a rescission of coverage as well as any other cancellation or discontinuance of coverage that has a retroactive effect, except when the cancellation/discontinuance is a result of failure to pay required Premiums or contributions toward cost of coverage.

The denial of payment for services or charges (in whole or in part) pursuant to Allegian Choice’s contracts with network providers, where You are not liable for such services or charges, are not Adverse Benefit Determinations.

Authorized Representative

 An individual you trust who is authorized in writing by you or state law to act on your behalf in requesting a health care service, obtaining claim payment, or during the internal appeal process. A health care provider may act on behalf of you without your express consent when it involves an Urgent Care Service.

Final Adverse Benefit Determination

An Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Allegian Choice, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.

Post-Service Claim

An Adverse Benefit Determination has been rendered for a service that has already been provided.

Pre-Service Claim

An Adverse Benefit Determination was rendered and the requested service has not been provided.

Urgent Care Services Claim

An Adverse Benefit Determination was rendered and the requested service has not been provided, where the application of non-urgent care appeal time frames could seriously jeopardize:

  • Your life or health or the your unborn child; or 
  • In the opinion of the treating physician, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Internal Appeal
You or your Authorized Representative or a treating Provider or facility may submit an appeal of an Adverse Benefit Determination. Allegian Choice will provide you with the forms necessary to initiate an appeal. You may request these forms by contacting Allegian Choice at the telephone number listed on the Member ID card.
If you are hearing impaired, you may also contact Allegian Choice via the Arizona Relay Service. You or your Authorized Representative must file an appeal within 180 days from the date of the notice of Adverse Benefit Determination. Within five business days of receiving an appeal, Allegian Choice will send you or your Authorized Representative a letter acknowledging receipt of the appeal.

The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination. It will include input from health care professional in the same or similar specialty as typically manages the type of medical service under review. 

Prior Authorization News

Some medical services as well as some prescription medications require prior authorization before members can receive. Please consult your primary care provider, who will be responsible to require prior authorization for you. Medical services as well as prescription drugs that require prior authorization can change the start or during the plan year.

TIMEFRAME FOR RESPONDING TO APPEAL

​REQUEST TYPES

TIMEFRAME FOR DECISION​

URGENT CARE SERVICE

WITHIN 72 HOURS.​

PRE-SERVICE AUTHORIZATION

WITHIN 30 DAYS.​

CONCURRENT SERVICE (A REQUEST
TO EXTEND OR A
DECISION TO REDUCE
A PREVIOUSLY APPROVED COURSE OF TREATMENT)​

WITHIN 72-HOURS FOR URGENT CARE SERVICES AND 30-DAYS FOR OTHER SERVICES.​

POST-SERVICE AUTHORIZATION​

WITHIN 60 DAYS.​


Exhaustion of Process

The following procedures and processes are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this “Complaints and Appeals' " section.

External Appeal

After you have exhausted the internal appeal rights provided by Allegian Choice, You have the right to request an external/independent review of an Adverse Benefit Determination. You or Your Authorized Representative may file a written request for an external review.

Your notice of Adverse Benefit Determination and Final Adverse Benefit Determination describes the process to follow if you wish to pursue an external appeal.

You must submit your request for external review within 123 calendar days of the date you receive the notice of Adverse Benefit Determination or Final Adverse Benefit Determination.

You can request an external appeal by fax at 1888-866-0205, [online at www.externalappeal.com] or by mail at: 

HHS Federal External Review Request
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

If you have any questions or concerns during the external appeal process, you or your Authorized Representative can call the toll-free number 1-888-866-6205. You or your Authorized Representative can submit additional written comments to the external reviewer at the mailing address above.

If any additional information is submitted, it will be shared with Allegian Choice in order to give us an opportunity to reconsider the denial.

Request for expedited external appeal
You or your Authorized Representative may make a written or oral request for an expedited external appeal with the external reviewer when you receive:

  • An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an appeal of an Urgent Care Service would seriously jeopardize Your life or health or would jeopardize Your ability to regain maximum function and You have filed a request for a review of an Urgent Care Service; or
  • A Final Adverse Benefit determination, if You have a Medical Condition where the timeframe for completion of a standard external review would seriously jeopardize Your life or health or would jeopardize Your ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received services, but has not been discharged from a facility.
  • An Adverse Benefit Determination that relates to Experimental or Investigational treatment, if the treating physician certified that the recommended or requested health care service, supply, or treatment would be significantly less effective if not promptly initiated.

In expedited external appeal situations, requests for expedited review can be initiated by calling MAXIMUS Federal Services toll free at 1-888-866-6205, or by faxing the request to 1-888-866-6190, or by mailing the request to:

HHS Federal External Review Request
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.

Additionally, at your request, Allegian Choice can send you copies of the actual benefit provision, and will provide a copy at no charge, of the actual benefit, clinical guidelines or clinical criteria used to make the determination upon receipt of your request. A request can be made by calling the Allegian Choice Grievances Investigator