If El Paso Health denies your appeal, your doctor can ask for a Specialty Review.  He must have a good cause for asking for the Specialty Review and has 10 days to request the Specialty Review.  The Specialty Review will be completed within fifteen (15) working days of the date the health care Provider requested the Specialty Review. Notification of the determination will be provided in writing by letter to you. You may also request an Independent Review Organization (IRO). The purpose of the external review, is to find out if El Paso Health made the right decision on the service or treatment you requested.
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An Expedited Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.
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You, someone acting on your behalf, or your doctor may file an Expedited Appeal with El Paso Health by calling or writing to the following:

El Paso Health
Attention: Complaints and Appeals Department
1145 Westmoreland Drive
El Paso, TX 79925
Tel: 915-532-3778
Toll Free: 1-877-532-3778
Fax No.: 915-298-7872
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No. You can request an Expedited Appeal orally or in writing.
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El Paso Health will let you know based on the seriousness of your condition, but in no case later than one working day from when El Paso Health receives all the information necessary to complete the Expedited Appeal. You will be notified by telephone or fax. You will also receive a letter within three working days following the phone or fax notification of the decision to your appeal.
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The expedited appeal will be treated as a regular appeal and the MCO has 30 days to resolve.
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The IRO is an independent, outside review of health care services that are denied by your health plan. The purpose of the external review, is to find out if El Paso Health made the right decision on the service or treatment you requested.
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You have four months to request a review by an IRO. You must first appeal to El Paso Health  If El Paso Health denies your request, you can request a review by an IRO by completing and signing the Request for Review by an HHS Federal External Review Request form included with your denial letter. You can also submit your appeal online at https://www.externalappeal.com/ferpportal.

The external review will be completed by MAXIMUS Federal Services. When MAXIMUS receives your request, they will notify us and we’ll send them all of the case information for review. If you send them any more information they’ll share it with us.  We may change our decision. If not, the IRO will continue the review. You’ll receive a letter with their decision. If MAXIMUS decides to overturn our decision, we will provide coverage or payment for your health care item or service.

You can call MAXIMUS at 1-888-866-6205 if you have questions about your external review.
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The IRO (MAXIMUS) will complete the review within 45 days of receipt for a Standard Appeal.
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If the decision is made in your favor, El Paso Health will comply with the IRO’s decision and authorize the disputed services promptly. El Paso Health will be responsible for the payment of services.

If the IRO agrees that the healthcare services were not medically necessary or appropriate, then services will not be covered by the health plan.The Member may qualify for free or low cost legal services by contacting the Texas Rio Grande Legal Aide located at 1331 Texas Avenue, El Paso, TX  79901, at phone number 915-585-5100, toll free at 1-800-369-2792, or fax at 915-544-3789. You can also contact El Paso Health at 915-532-3778 or toll free at 1-877-532-3778 for assistance.

If you wish to file a complaint with El Paso Health, you can contact us at:
El Paso Health
Attn: Complaints and Appeals Department
1145 Westmoreland Dr.
El Paso, TX 79925
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If you wish to file a complaint with TDI, you can contact TDI at:
Texas Department of Insurance
Consumer Protection
P.O. Box 149091
Austin, Texas 78714-9091
Phone:  1-800-252-3439
Email: http://www.tdi.texas.gov/consumer/complfrm.html