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Provider Complaints and Appeals

Provider Complaints Process to HMO

As a STAR health plan, it is the policy of Texas Children’s Health Plan to adhere to State Medicaid Provider Guidelines as defined in the current edition of the Texas Medicaid Provider Procedures Manual. A complaint includes any dissatisfaction with any aspect of Texas Children’s Health Plan’s operations, including plan administration, the appeal of an adverse determination, the denial, reduction, or termination of a service, the way a service is provided, or disenrollment decisions, may file a complaint or appeal with Texas Children’s Health Plan. The following information will assist providers in filing.

Complaint Issues

Providers dissatisfied with any aspect of Texas Children’s Health Plan’s operations may file a written or verbal complaint with Texas Children’s Health Plan at the following address:

Texas Children’s Health Plan
Attention: Provider & Care Coordination
Provider and Care Coordination NB 8301
PO Box 301011
Houston, TX 77230-1011
Phone: 832-828-1008
Fax: 832-825-8750
Email: TCHPProviderConcerns@tchp.us

Texas Children’s Health Plan will send a written acknowledgement of a complaint within 5 business days. Texas Children’s Health Plan will investigate and issue a response to a provider complaint within 30 calendar days. All appeals of denied claims and requests for adjustments on paid claims must be received by Texas Children’s Health Plan within 120 days from the last date of disposition; the date of the Explanation of Benefits on which that claim appears. Notification of receipt of the request for an appeal will be sent to the provider within 5 business days of receipt of the request. Provider appeals will be responded to within 30 calendar days. If a provider appeal involves a presently occurring emergency, denial of a continued hospital stay, or life-threatening condition, Texas Children’s Health Plan shall respond in accordance to the medical immediacy of the case but in no event, greater than 1 business day from the time Texas Children’s Health Plan receives the appeal. Texas Children’s Health Plan will provide an oral resolution decision within 1 business day of receipt of an expedited appeal and in writing within 3 business days. All provider appeals involving medical necessity issues will be made by a physician.

If an appeal is denied, the provider has 30 working days to set forth in writing good cause for having a particular type of specialty provider review the case, and the denial shall be reviewed by a provider in the same or similar specialty as typically manages the member’s situation. An acknowledgement letter will be sent within five working days of receiving request for specialty review.

Specialty review will be completed within 15 working days of receipt of request. Claims lacking the information necessary for processing are listed on the Explanation of Benefits requesting the missing information. Providers must resubmit a completed/corrected claim to Texas Children’s Health Plan within 120 days from the date of the Explanation of Benefits to be considered for payment.

Appeal Issues—Services Already Rendered

Medical Necessity Appeals/Appeals to a Denial for Service Authorization

If Texas Children’s Health Plan denies a provider’s request for service authorization due to medical necessity, a provider has 30 calendar days to request an appeal. To request an appeal, please send your written request to:

Texas Children’s Health Plan
Attention: Appeals Department
PO Box 300709 NB 8390
Houston, TX 77230
Fax: 832-825-8750

To assist Texas Children’s Health Plan in your request, please state the reason you are requesting your appeal and submit supporting medical documentation. Texas Children’s Health Plan will acknowledge in writing your request within 5 business days, and if necessary, request specific medical information to support your appeal. If you do not provide Texas Children’s Health Plan with the requested medical information within 10 days, Texas Children’s Health Plan will make its decision based on the information provided. Texas Children’s Health Plan will respond to your appeal within 30 calendar days.

All appeals of adverse determination for which medical records are not received within 30 calendar days of the filing date will be finalized and the original decision will be upheld. This decision is final and binding, and the provider will have exhausted his/her appeal rights with Texas Children’s Health Plan.

Texas Children’s Health Plan Provider and Care Coordination | 832-828-1008

Expedited Appeals to a Denial for Service Authorization

If Texas Children’s Health Plan denies a request for services and a member’s medical condition may be jeopardized by the standard 30 calendar day appeal timeframe, a provider may request an expedited appeal review. To request an expedited review, please fax the request to 832-825-8796. Texas Children’s Health Plan will respond to expedited appeals involving emergency services or continued hospitalization within 1 business day.

Second Level Appeals to a Denial for Service Authorization
If Texas Children’s Health Plan upholds its decision to deny authorization for requested services due to medical necessity, you have a right to request a second review from a different provider in the same or similar specialty. You must file your request within 30 calendar days from receipt of Texas Children’s Health Plan appeal decision and set forth in writing good cause for having a particular specialty review.

To request a specialty review, please send your request to:

Texas Children’s Health Plan
Attention: Appeals Department
PO Box 300709 NB 8390
Houston, TX 77230

Texas Children’s Health Plan will complete its specialty review within 15 business days from receipt of your request.

Provider Complaints to Texas Health and Human Services Commission

Providers may file complaints to HHSC if they feel they did not receive full due process from Texas Children’s Health Plan. The commission is only responsible for the management of complaints for managed care providers. Appeals/grievances, hearings, or dispute resolution are the responsibility of the Health Plan.

Complaints must be in writing and mailed to:

Texas Health and Human Services Commission
Re: Provider Complaint
Health Plan Operations, H-320
PO Box 85200
Austin, TX 78708
HPM_Complaints@hhsc.state.tx.us