CHP+ Health Insurance in Colorado

 

Child Health Plan Plus (CHP+) is a low-cost health insurance plan for children from birth through age 18, administered by the State of Colorado’s Department of Health Care Policy and Financing. Children who are approved for CHP health insurance Colorado must enroll with a managed care organization in order to access benefits of the program. Children who live in Alamosa, Baca, Bent, Chaffee, Cheyenne, Conejos, Costilla, Crowley, Custer, Fremont, Huerfano, Kiowa, Kit Carson, Las Animas, Mineral, Otero, Prowers, Rio Grande, Saguache, Washington, and Yuma counties can enroll with Friday Health Plans of Colorado as their managed care organization.

Here are some tools to help you decide if we’re the right health plan for you, and to provide support if you are already a Friday Health Plans of Colorado member or acting as the Designated Client Representative for a member.

Plan and Benefit Information

CHP+ Member Handbook

  • The CHP+ Member Handbook is a comprehensive guide that explains how to access the services and programs available to you through Friday Health Plans of Colorado. You can find information about Getting Care, Process for Getting Covered Services, Your Friday Health Plans of Colorado Benefits and Services, and more, in the CHP+ Member Handbook.

Click here to download the CHP+ Member Handbook in PDF format.  To view the CHP+ Member Handbook document, you will need to have Adobe Acrobat Reader installed on your system. Click on the following link to download Acrobat Reader.

http://www.adobe.com/products/reader.html.

CHP+ Summary of Benefits

  • The CHP+ Summary of Benefits is a guide to the major categories of health services that are covered benefits under your Friday Health Plans of Colorado membership. It also lists any financial responsibility, such as copays, coinsurance, or deductibles, you may have when receiving these services.

Click here to download the Summary of Benefits in PDF format

To view the Summary of Benefits document, you will need to have Adobe Acrobat Reader installed on your system. Click on the following link to download Acrobat Reader http://www.adobe.com/products/reader.html.

Friday Health Plans of Colorado

Friday Health Plans of Colorado has been serving Colorado for over 40 years.  We are a community focused organization, and are well known in our communities for understanding rural and underserved health care needs. We have expanded over the last few years into additional non-rural counties, but have not lost the values from our rural roots. Our focus continues to be on community and the responsibility that comes when our members are our neighbors, friends, and family.

How to Find a Doctor

  • The CHP+ Provider Directory is a comprehensive listing at one point in time of the providers available to you in the Friday Health Plans of Colorado network. The directory includes a listing of doctors & specialists, their gender, locations, telephone numbers, additional languages some providers have available, and what specialty, if any, per provider.
  • Friday Health Plans of Colorado specializes in serving rural and underserved counties in south central Colorado and on the eastern plains. We make every effort to contract with every facility and every provider located in the communities we serve.
  • To look up a specific provider, find a provider close to your home, or obtain a current copy of the provider directory customized to you, please log in to your Friday Member Portal account. (You must be a member of Friday Health Plans of Colorado to obtain a Friday Member Portal account.
  • If you would like us to send you a copy of the Provider Directory, please call our customer service department.
  • CHP Pharmacy List

Selecting or Changing a Primary Care Provider (PCP)

  • As a Friday Health Plans of Colorado Member, you must pick a Primary Care Provider (PCP) from our PCP Provider Directory that lists our Participating PCPs. You can choose a PCP for each child enrolled. Your child’s PCP will provide medical care and help coordinate his or her care. A PCP can be one of the following types of providers:

Family and General Practice – usually can see the whole family

Internal Medicine – usually sees only adults and children 14 years or older

Pediatrician – sees children from newborn to age 18 or 21

Please call Customer Service at 719-589-3696, or 1-800-475-8466, if you want to select or change your child’s PCP.

 

Online Self Service Tools

Friday Member Portal

  • Friday Member Portal is our secure member portal that is easy to navigate and full of ways to help you take control of your health. The Friday Member Portal provides the following three main categories of information.
  • My Health helps you manage your health by giving you access to your medical history, the medications you have taken, your appointments, the illnesses/conditions diagnosed by physicians you have seen, and a summary of your medical visits. You can also collaborate with your Primary Care Provider to develop “My Plan For Health” which is your personal record of health concerns and your plan to manage them.
  • My Providers gives you a history of providers that you have seen
  • My Health Plan gives you up to date information about your health care coverage through Friday Health Plans of Colorado. With My Health Plan, you can quickly obtain current information about your benefits and eligibility, and look up claims to determine the amounts paid or denied. You can request a new ID card should yours become lost or damaged. You can also use My Health Plan to print a temporary card at home. You can even view the status of a referral to ensure your visit is approved before the specialist visit. If your personal information changes, such as a name change due to marriage or divorce, you can submit member information and contact information changes to Friday Health Plans of Colorado through the Friday Member Portal using the secure messaging option.
  • My Resources gives you access to additional web sites and other online resources to help answer your medical questions. The Formulary gives you information about thousands of medications including how to use the medications and whether the medication is preferred generic, preferred brand, or non-formulary according to your health plan. Healthwise is a leading medical information tool designed to “help people make better health decisions.” Use Healthwise to learn more about medical conditions so you can have meaningful discussions about your concerns with your health care providers. SLV Resources links you to additional assistance provided by Friday Health Plans of Colorado.

Click here  to download instructions for accessing the Friday Member Portal.

Frequently Asked Questions

Who do I contact if I have questions about my eligibility for the CHP+ program?

  • Call CHP+ Customer Service at 1.800.359.1991
  • Visit CHP+ website @ cchp.org

Who do I call if I have questions about my CHP+ benefits?

  • Contact Friday Health Plans of Colorado at 589.3696, if calling from within the San Luis Valley, or 1.800.475.8466, if calling from outside the valley, so we can help you understand the programs and services available to you as a Friday Health Plans of Colorado member

What if I need a new member identification card?

  • Contact Friday Health Plans of Colorado at 589.3696 if calling within the San Luis Valley, or 1.800.475.8466, if calling from outside the valley, so we can send you a new member ID card. You can also log in to your Friday Member Portal account to print a temporary membership card and request a new membership card

How do I select a PCP?

  • Please call Customer Service at 719.589.3696, if calling from within the San Luis Valley, or 1.800.475.8466, if calling from outside the valley, if you want to select or change your child’s PCP.

What if I get a bill from the doctor?

  • Contact Friday Health Plans of Colorado at 589.3696 if calling from within the San Luis Valley, or 1.800.475.8466, if calling from outside the valley, so we can help you determine benefits and understand your medical claims

Who do I call if I want to choose a different managed care organization?

  • Contact Health Colorado at 1.800.359.1991

Grievances and Appeals

  • A ‘grievance’ is an oral or written expression of dissatisfaction about any matter other than an Adverse Benefit Determination
  • An ‘appeal’ means a request for a review of an Adverse Benefit Determination.

How do I file a grievance?

  • You or your DCR can call or write Friday Health Plans of Colorado CHP+ Customer Service Department. You should do this at any time. Be sure to include your name, Member ID number, State identification (ID) number, address, and phone number.

Friday Health Plans of Colorado

Grievance and Appeals Department

700 Main Street, Suite 100

Alamosa, Colorado 81101

How do I File an Appeal?

You have the right to file an appeal with Friday Health Plans of Colorado. An appeal is a request for review of an Adverse Benefit Determination being taken by Friday Health Plans of Colorado. If Friday Health Plans of Colorado takes an action, you and your provider will get a Notice of Action (Adverse Benefit Determination) letter that tells you why. This Notice of Action Letter (Adverse Benefit Determination) will also explain how to appeal if you want to.

Notice of Action Letter

This is a written letter that Friday Health Plans of Colorado will send to you if Friday Health Plans of Colorado is making any change (action) to any part of your Friday Health Plans of Colorado services.  The Notice of Action Letter will include:

  • The action (Adverse Benefit Determination) Friday Health Plans of Colorado intends to take;
  • The reason for the action (Adverse Benefit Determination), including the right of the member to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the member’s Adverse Benefit Determination. Such information includes medical necessity criteria and any processes, strategies, or evidentiary standards used in setting coverage limits;
  • The Member’s or the Designated Client Representative’s right to file an MCO appeal
  • The date the appeal is due;
  • The Member’s right to request a State fair hearing;
  • The procedures for exercising the right to a fair hearing;
  • The circumstances under which expedited resolution is available and how to request it;
  • The Member’s right to have benefits continue pending resolution of the appeal, and how to request that benefits be continued; and
  • The circumstances under which the Member may be required to pay the cost of these services.

For denial of payment, the Notice of Action Letter should be sent at the time of any action affecting the claim.

For standard service authorization decisions that deny or limit services, the Notice of Action letter should be sent within ten (10) calendar days. For expedited service authorizations, within seventy-two (72) hours.

Advance Notice of Action

Friday Health Plans of Colorado must let you know about an action before the action happens. If Friday Health Plans of Colorado plans to stop paying for or reducing any services you have been getting, we have to send you a Notice of Action letter ten (10) calendar days before the date we stop paying for or reducing services. Friday Health Plans of Colorado can shorten the timeframe to five (5) calendar days if:

  • There are verified facts indicating probable fraud by the Member;

Friday Health Plans of Colorado can mail the notice not later than the date of action if:

  • There is factual information confirming the death of the Member;
  • There is a clear written statement signed by the Member stating that he/she no longer wishes services. The letter must have information that requires termination or reduction of services.
  • The Member has been admitted to an institution where he/she is ineligible under the plan for further services;
  • The Member’s whereabouts is unknown and the post office returns mail directed to him or her indicating no forwarding address;
  • Friday Health Plans of Colorado establishes the fact that the Member has been accepted for Medicaid services by another local jurisdiction, state, territory, or commonwealth;
  • A change in the level of medical care is prescribed by the Member’s physician;
  • The notice involves an action (Adverse Benefit Determination) made with regard to the preadmission screening requirements of 1919(e)(7) of the Social Security Act; or
  • Notice may be made as soon as practicable before transfer or discharge when:
  • The safety of individuals in the facility would be endangered;
  • The health of individuals in the facility would be endangered;
  • The resident’s health improves sufficiently to allow a more immediate transfer or discharge;
  • An immediate transfer or discharge is required by the resident’s urgent medical needs; or
  • A resident has not resided in the facility for 30 days.

You can appeal any of the following defined actions (Adverse Benefit Determination):

The denial or limited authorization of a requested service, including the type or level of service,

  • The reduction, suspension, or termination of a previously authorized service,
  • The denial, in whole, or in part, of payment for a service,
  • The failure to provide services in a timely manner,
  • The failure to act within the timeframes for resolution of grievances and appeals, or
  • For a resident of a rural area with only one MCO or PIHP, the denial of a CHP+ Member’s request to exercise his or her rights to obtain services outside of the network under the following circumstances:
    • The service or type of provider (in terms of training, expertise, and specialization) is not available within the network,
    • The provider is not part of the network, but is the main source of a service to the Member provided that
      • The provider is given the opportunity to become a participating provider,
      • If the provider does not choose to join the network or does not meet the health plan’s qualification requirements, the Member will be given the opportunity to choose a participating provider and then will be transitioned to a participating provider within 60 days.
      • The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.

If you or your DCR asks for an appeal, we will review the decision. Your provider may file an appeal for you or help you with your appeal as your DCR. For a DCR to get your medical records for an appeal, you or your legal guardian must give written permission to your provider.

You will not lose your benefits if you file an appeal. If you are getting services that have already been approved by Friday Health Plans of Colorado CHP+, you may be able to keep getting those services while you appeal, if all of these requirements are met:

  • Your appeal has been sent to us within the required timeframes by you or your provider;
  • A Friday Health Plans of Colorado CHP+ Provider has asked that you receive the services;
  • The time period that the approval (authorization) of the services has not ended; and
  • You specifically request that the services continue.

You may have to pay for services that you get during the appeal if you lose the appeal. If you win the appeal you will not have to pay. Please let us know when you ask for an appeal if you want to keep getting your services.

If you continue getting the approved services, they will continue for a certain period of time. The services will continue until:

  • You withdraw your appeal.
  • A total of ten (10) calendar days pass after we mail the original notice to you that we are denying your appeal. If you request a State fair hearing within those ten (10) calendar days, your benefits will continue until the hearing is finished.
  • The State fair hearing office decides that your appeal is denied.
  • The authorization for the service ends.

Examples of decisions that you could appeal include:

  • You are told you are being discharged from the hospital and don’t feel ready to go.
  • Denial of continued services, such as physical therapy, that you feel are still needed.

How to Ask for an Appeal of a Decision or Action:

  • If the appeal is about a new request for services, you or your DCR must request an appeal within sixty (60) calendar days from the date on the letter saying what action Friday Health Plans of Colorado CHP+ has taken, or plans to take.
  • If you appeal an action where the plan lowered, changed or stopped a previously authorized service, you must file your appeal on time. On time means:
  • within sixty (60) calendar days from the mailing date of the decision (notice of action) letter; or
  • If you want to continue services during your appeal you must file within ten (10) calendar days from the mailing date of the decision or before the date that the action will take effect.

You or your DCR can call Friday Health Plans of Colorado CHP+ Grievance and Appeal Department to start your appeal. The phone number is 719-589-3696 or 1-800-475-8466. Tell them you are a Colorado Choice CHP+ Member. Tell them which decision or action you want to appeal. If you call to start your appeal, you or your DCR must send us a letter after the phone call. The letter must be signed by you or your DCR. The letter must be sent to:

Friday Health Plans of Colorado

Grievance and Appeal Department

700 Main Street, Suite 100

Alamosa, Colorado 81101

  • You or your DCR can request a “fast” or “expedited” appeal if you are in the hospital, or feel that waiting for a regular appeal would threaten your life or health. The section called “Expedited (Fast) Appeals” tells you more about expedited appeals.

Get Help Filing an Appeal:

If you want help with any part of the appeal process, please contact us. We can help you with any questions you have, provide reasonable assistance in completing any forms required, put oral requests for appeals or a State fair hearing into writing, and take other procedural steps, including, but not limited to, providing interpreter services. Call Customer Service at 719-589-3696 or at 1-800-475-8466; TTY users should call 1-800-659-2656. You will not lose your CHP+ benefits if you appeal an action! It is the law!

What Happens with an Appeal:

After we receive your phone call or letter, you will get a letter within two (2) working days. This letter will tell you that we got your request for an appeal.

You or your DCR can tell us in person or in writing why you think Friday Health Plans of Colorado  CHP+ should change its decision or action. You or your DCR can also give us any information or records that you think would help your appeal, including evidence and testimony and make legal and factual arguments. Friday Health Plans of Colorado will take into account all comments, documents, records or other information you or your DCR submit without regard to whether such information was submitted or considered in the initial adverse benefit determination. You or your DCR can ask questions, and ask for the criteria or information that was used to make the decision. You or your DCR can look at Friday Health Plans of Colorado’s member’s case file, including medical records, other documents and records, and any new or additional documents considered, relied upon, or generated by Friday Health Plans of Colorado in connection with the appeal.  This information will be provided by Friday Health Plans of Colorado free or charge.

If the decision or action you are appealing is about a denial or change of services, a doctor will review your medical records and other information. This doctor will not be the same doctor who made the first decision.

Friday Health Plans of Colorado CHP+ will make a decision and notify you within ten (10) working days from the day we get your request. We will send you a letter that tells you the decision and the reason for the decision.

If we need more information and the delay is in the Member’s best interest, we may take more time to make the decision. The extended timeframe for the resolution of the appeals can be by up to fourteen (14) calendar days. We will send you a letter to let you know along with the reason the time frame was extended. Or, you or your DCR can ask for more time.

Friday Health Plans of Colorado will notify the Member in writing of the resolution of an appeal and the date it was completed. Reasonable efforts will be made to provide oral notice.

If the appeal was not resolved wholly in favor of the member the following should be included in the notification to the member:

The right to request a State fair hearing and how to do so

The right to request and to receive benefits while the hearing is pending, and how to make the request; and

That the member may be held liable for the cost of those benefits if the hearing decision upholds the MCO’s action.

Expedited “Fast” Appeals

If you feel that waiting for an appeal would seriously affect your life or health, you may need a decision from Friday Health Plans of Colorado CHP+ fast. You or your DCR can ask for an expedited “fast” appeal. For a fast appeal, a decision will be made within seventy-two (72) hours, instead of ten (10) working days for a regular appeal.

We will make our decision on an expedited appeal within seventy-two (72) hours. This means that you or your DCR have a short amount of time to look at our records and give us information. You can give us information in person or in writing. During this time, your services will stay the same. Friday Health Plans of Colorado will provide oral and written notice of the expedited appeal resolution.

Friday Health Plans of Colorado will not take punitive action against a provider who requests an expedited resolution or supports a Member’s appeal.

The plan can extend the timeframe by fourteen (14) calendar days if the delay is requested by the member; if the MCO shows that there is a need for additional information and that the delay is in the Member’s best interest. The MCO shall make reasonable efforts to give the member prompt oral notice of the delay and within two (2) calendar days, give the member written notice of the reason for the delay and inform the member of the right to file a grievance if he or she disagrees with that decision.

If your request for a fast appeal is denied, Friday Health Plans of Colorado CHP+ will call you as soon as possible to let you know. We will also send you a letter within two (2) working days. Then we will review your appeal the regular way. Upon review, you will get a letter that tells you the decision of the appeal and the reason.

How to Request a State Fair Hearing

A State Fair Hearing means that a State Administrative Law Judge (ALJ) will review Friday Health Plans of Colorado’s decision or action. You have the right to request a State Fair Hearing after the MCO level Appeal process has been exhausted:

  • The member shall request a State Fair Hearing within one hundred and twenty (120) calendar days from the date of the MCO’s notice of Appeal determination.
  • If Friday Health Plans of Colorado fails to adhere to the notice and timing requirements regarding resolution and notification of an Appeal, the member is deemed to have exhausted the Appeals process and may request a State Fair Hearing.

A Request for a State Fair Hearing Must be Submitted in Writing

  • If your request is about a treatment that has not been approved before, you or your DCR must make the request within sixty (60) calendar days from the date on the letter that tells you the action that Friday Health Plans of Colorado has taken, or plans to take.
  • If your request is about treatment that has been approved before, you or your DCR must make the request within sixty (60) calendar days from the date on the letter that tells you the action that Friday Health Plans of Colorado has taken, or plans to take.
  • If you want to continue services during your request for a State Fair Hearing you must file within ten (10) calendar days from the mailing date of the decision or before the effective date of the termination or change in services, whichever is later.
  • Continuation of benefits will be continued if:
  • The enrollee or the provider files the appeal timely
  • The appeal involved the termination, suspension, or reduction of a previously authorized course of treatment
  • The services were ordered by an authorized provider
  • The original period covered by the original authorization has not expired; and
  • The enrollee requests extension of benefits
  • Duration of continued benefits
  • If benefits are continued while the appeal is pending, the benefits must be continued until one of the following occurs:

The enrollee withdraws the appeal.

Ten days pass after the MCO mails the notice, providing the resolution of the appeal against the enrollee.

A State fair hearing Office issues a hearing decision adverse to the enrollee.

The time period or service limits of a previously authorized service has been met.

If you or your DCR want to ask for a State Fair Hearing, you or your DCR may call or write to:

Office of Administrative Courts

1525 Sherman Street, 4th Floor

Denver, CO 80203

Phone: (303) 866-2000

Fax: (303) 866-5909

The Office of Administrative Courts will send you a letter that explains the process and will set a date for your hearing.

You can talk for yourself at a State Fair Hearing by the Administrative Law Judge or you can have a DCR talk for you. A DCR can be a lawyer, a relative, an advocate, or someone else. The Judge will review Friday Health Plans of Colorado’s decision or action.

We encourage you to keep within the calendar day deadline to protect your right to the hearing. The State Fair Hearing / ALJ contact information is provided above. You must make your request for the hearing in writing and you must sign your request.

If you are getting services that have already been approved by Colorado Choice, you may be able to keep getting those services while you are waiting for the Judge’s decision. But if you lose at the State Fair Hearing, you may have to pay for services that you get while you are appealing. If you win, you will not have to pay.

Important Changes for 2017

  • It’s a new day in health insurance! Colorado Choice is not part of Friday Health Plans. Your insurance plan and great service remain unchanged, but look for our new name on all your documents, Friday Health Plans of Colorado.

Forms and Additional Resources

Additional Resources

  • CHP+ Customer Service: 1.800.359.1991
  • CHP+ website: cchp.org
  • Health Colorado: 303.839.2120 or 1.888.367.6557 (selecting an HMO)

How to Contact Us:

Telephone: 719.589.3696 or 1.800.475.8466
TTY: 1.800.659.2656
Fax: 719.589.4901
Address:
700 Main Street, Suite 100
Alamosa, CO 81101
Hours: 8:00 a.m. – 5:00 p.m., Monday through Friday

Translation services are available by contacting Customer Service.

Servicios de tradducion están disponibles contactando a servicio al cliente.

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