Grievance and Appeals

Learn more about processing Grievances, Fair Hearings, and Appeals

At CareFirst CHPDC we work hard to ensure that all of our enrollees receive the care they need. We are committed to you and your family. Should you wish to file a dispute, claim or appeal, the following information will help. Below you will find information on filing grievances, and appeals.

Grievance

If the care you received was less than satisfactory, or something happened to you when you received health care services from one of our providers you should file a grievance.

Examples of reasons you might file a Grievance:

• The care you received was not satisfactory.
• You were not treated with respect.
• Getting an appointment took too long.

Grievances can be filed by speaking with your primary care provider or by contacting Enrollee Services at (202) 821-1100 or (855) 872-1852. There is no time limit to file your grievance.

Appeals

If your benefits have been denied, reduced, delayed or stopped due to reasons that you believe are incorrect or unfair, CareFirst CHPDC enrollees have the right to appeal the decision within 60 days of receiving a Notice of Action from CareFirst CHPDC. To file an appeal contact Enrollee Services at (202) 821-1100 or (855) 326-4831.

Submit Written Appeals To:

CareFirst CHPDC
Attention: Appeals Coordinator
Attn: Grievances and Appeals Department
1100 New Jersey Ave., SE Ste. 840
Washington, DC 20003
Or Call (202) 821-1100 or (855) 872-1852

Fair Hearings

Those who have been unfairly denied benefits also have the option of requesting a Fair Hearing from the DC Office of Administrative Hearings. A Fair hearing gives you the opportunity to tell an Administrative Law Judge why you think the decision made is incorrect or unfair. Fair Hearings can be requested by contacting the District government at:

District of Columbia Office Administrative Hearings Clerk of the Court
441 4th Street, NW
Suite 4150
Washington, DC 20001
Phone: (202) 442-9094

Fair Hearings must also be requested within 120 days of receiving a Note of Action from CareFirst CHPDC. At any time you can contact the District’s Ombudsman office at (202) 724-7491

Continuation of Service During Appeals and Fair Hearings

You have the option of continuing to receive benefits during your appeal or Fair Hearing but you must file an appeal or request for a Fair Hearing:

• Within 10 days from the postmark of the Note of Action.

• - OR -

• Before the intended effective date of the proposed action.

If given your permission, your PCP may file an appeal or request a Fair Hearing on your behalf.