If you, as a member of El Paso Health, disagrees with our internal appeal decision, you have the right to ask for an External Medical Review (EMR). An EMR is an optional, extra step you can take to get the case reviewed for free before the State Fair Hearing. You may name someone to represent you by writing a letter to El Paso Health telling us the name of the person the Member wants to represent you. A provider may be your representative. You or your representative must ask for the External Medical Review within 120 days of the date El Paso Health mails the letter with the internal appeal decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review. To ask for an External Medical Review, your or your representative should either:
Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to El Paso Health’s appeal decision Notice of the Internal Appeal Decision letter and mail or fax it to El Paso Health by using the address or fax number at the top of the form.
Call El Paso Health at
915-532-3778 or toll free at
1-877-532-3778 for STAR Medicaid or toll free at
1-833-742-3127 for STAR+PLUS.
If you ask for an External Medical Review within 10 days from the time you get the appeal decision from El Paso Health, you have the right to keep getting any service El Paso Health denied, at least until the final State Fair Hearing decision is made. If you do not request an External Medical Review within 10 days from the time you get the appeal decision from El Paso Health, the service El Paso Health denied will be stopped.
You may withdraw your request for an External Medical Review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing your External Medical Review request. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an External Medical Review during your appeal processes related to Adverse Benefit Determinations based on functional necessity or medical necessity. An External Medical Review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.
Once the External Medical Review decision is received, you have the right to withdraw the State Fair Hearing request. It is your responsibility, your authorized representative, or your LAR to withdraw a State Fair Hearing request. If you, your authorized representative, or your LAR does not withdraw the State Fair Hearing request, regardless of the EMR decision, you, your authorized representative, or your LAR is required to attend the State Fair Hearing.
