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ATTENTION MEMBERS: 2023 Covid-19 vaccine currently not covered on Texas Medicaid and CHIP Formulary | Learn more
Flexible appeal policy ending soon! | Learn more

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STAR Kids Member Resources

Here you'll find important information about your STAR Kids plan.

Searchable handbook 

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You can file a complaint or an appeal by contacting your health plan. Information on the complaint and appeal process will be included in your STAR Kids member handbook, which your health plan will send you. Read more

You can also request a fair hearing from the State by following the instructions in the member handbook and on the health plan denial letter for State Fair Hearings. 

State Fair Hearing Contact information: Call 1-800-659-5764 or TDD 1-800-735-2989

If you receive benefits through Medicaid’s STAR or STAR Kids Program, call your medical or dental plan first. If you don’t get the help you need there, you should do one of the following:  

Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).  

Online: https://hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman  

Mail:

Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247  

Fax: 1-888-780-8099 (toll-free);

A State Fair Hearing is a chance for you tell the reasons why you think the services you asked for and couldn’t get should be allowed.

Can I ask for a State Fair Hearing? If you, as a member of Texas Children’s Health Plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by Texas Children’s Health Plan, you or your representative must ask for the fair hearing at any time up until 90 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 90 days, you may lose your right to a State Fair Hearing.To ask for a fair hearing, you or your representative should either send a letter to the health plan or call:

Texas Children’s Health Plan
Attention: Appeals Department NB8390
PO Box 300709
Houston, TX 77230
Fax: 832-825-8796
Phone: 832-828-1001 or 1-866-959-2555
TDD 1-800-735-2989 (Texas Relay) or 7-1-1

Click here for more information on State Fair Hearings

HHSC continues to require of Texas Children’s Health Plan to allow an extension for up to 30 days for members to request continuation of benefits after they receive an adverse benefit determination. This continuation of benefits extension time frame will end June 30, 2021.

Starting July 1, 2021, Texas Children’s Health Plan must apply the normal, regular and set timeframes for members to request continuation of benefits, which is no later than 10 days from the date they receive the adverse benefit determination notice.

Can a Member ask for an External Medical Review?

If a Member, as a member of the health plan, disagrees with the health plan’s internal appeal decision, the Member has the right to ask for an External Medical Review. An External Medical Review is an optional, extra step the Member can take to get the case reviewed before the State Fair Hearing occurs. The Member may name someone to represent them by contacting the health plan and giving the name of the person the Member wants to represent him or her. A provider may be the Member’s representative. The Member or the Member’s representative must ask for the External Medical Review within 120 days of the date the health plan mails the letter with the internal appeal decision. If the Member does not ask for the External Medical Review within 120 days, the Member may lose his or her right to an External Medical Review. To ask for an External Medical Review, the Member or the Member’s representative may either:

Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to the Member Notice of MCO Internal Appeal Decision letter and mail or fax it to Texas Children’s Health Plan by using the address or fax number at the top of the form.

Texas Children's Health Plan

Attn: UM Department

P.O. Box 301011, WLS 8390

Houston, TX 77230-1011

Fax: 832-825-8796

Call Texas Children’s Health Plan at 866-959-2555 (STAR) or 800-659-5764 (STAR KIDS) or email us at TCHPUM@texaschildrens.org 

If the Member asks for an External Medical Review within 10 days from the time the Member gets the appeal decision from the health plan, the Member has the right to keep getting any service the health plan denied, based on previously authorized services, at least until the final State Fair Hearing decision is made. If the Member does not request an External Medical Review within 10 days from the time the Member gets the appeal decision from the health plan, the service the health plan denied will be stopped.

The Member may withdraw the Member’s request for an External Medical Review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing the Member’s External Medical Review request. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an External Medical Review during Member 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, the Member has the right to withdraw the State Fair Hearing request. If the Member continues with the State Fair Hearing, the Member can also request the Independent Review Organization be present at the State Fair Hearing. The Member can make both of these requests by contacting Texas Children’s Health Plan at 866-959-2555 (STAR) or 800-659-5764 (STAR KIDS) or the HHSC Intake Team at EMR_Intake_Team@hhsc.state.tx.us If the Member continues with a State Fair Hearing and the State Fair Hearing decision is different from the Independent Review Organization decision, it is the State Fair Hearing decision that is final. The State Fair Hearing decision can only uphold or increase Member benefits from the Independent Review Organization decision.

Can I ask for an emergency External Medical Review?

If you believe that waiting for a standard External Medical Review will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you, your parent or your legally authorized representative may ask for an emergency External Medical Review and emergency State Fair Hearing by writing or calling Texas Children’s Health Plan. To qualify for an emergency External Medical Review and emergency State Fair Hearing review through HHSC, you must first complete Texas Children’s Health Plan internal appeals process.

Texas Children’s Health Plan provides a Member Advocate to assist you if you have a complaint. Our team of member advocates will help you write and file a complaint or appeal on your behalf and monitor it until it is resolved. We have a member advocate dedicated for each line of business and service delivery area. We speak English and Spanish. We also have interpreters available by phone who speak 140 different languages.

To have a Member Advocate assigned to you, call 866-219-5411.

Our Member Services Team is ready to take your call from 8 a.m. to 5 p.m., Monday through Friday. After hours, on weekends and holidays, our answering service is ready to help you and/or take your messages. A Member Service Advocate will return your call the next business day. We speak English or Spanish. We also have interpreters available by phone who speak 140 different languages. Emergency Service and Behavioral Health services are available 24 hours a day, 7 days a week.

Here are some services our team can help you with, if needed.

  • Oral interpretation (over the phone and face to face) and written translations assistance. Sign language available.
  • Information in formats such as print, Braille, audiotapes or accessible electronic.
  • Access to TTY/TDD services for hearing and speech impairment

Member Services Program Hotlines:

  • CHIP: 1-866-959-6555
  • STAR: 1-866-959-2555
  • STAR Kids: 1-800-659-5764 (Service Coordination)
  • TTY/TDD: 1-800-735-2989 (Texas Relay) or 7-1-1

In case of an emergency, go to your nearest in-network emergency room or call 9-1-1.

Regular checkups and shots keep your children healthy. You can go to any Texas Health Steps doctor without a referral. To find a Texas Health Steps (THSteps) doctor near you, call us at 1-866-959-2555 or use our "Find a Doctor" tool.

For more information visit www.TXHealthSteps.com

Learn more about Prior authorization.

Texas Children’s Health Plan will host quarterly Member Advisory Group meetings to gain valuable feedback from our current members on the initiatives, services, and programs offered by the health plan. The information and member feedback gathered during these meetings will be used to guide future programs.

The meetings are mandated by the state, and will last no longer than one hour. These groups help our diverse population by implementing cultural and linguistic services that meet their needs. TCHP must maintain a record of member advisory group meetings, including agendas, and minutes.

To join and learn more, call Care Coordination at 832-828-1430

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We care about protecting your privacy, you can view our privacy practices online.
 

What is Service Coordination?

Service Coordination provides initial and ongoing assistance identifying, selecting, obtaining, coordinating, and using Covered and Non-Covered services and supports to enhance a Member’s well-being, independence, integration in the community, and potential for productivity.

What will a Service Coordinator do for me?

  • Provide a holistic evaluation of individual dynamics, needs and preferences.
  • Educate and help provide health-related information;
  • Help identify any physical, behavioral, functional, and psychosocial needs;
  • Work with the Member and the Member’s LAR and other caretakers in the design of an Individual Service Plan (ISP);
  • Connect Members to Covered and non-covered services necessary to meet identified needs;
  • Monitor to ensure access to covered services is timely and appropriate;
  • Coordinate Covered and non-Covered Services; and
  • Intervene on behalf of the Member if approved by the Member/LAR.

How can I talk with a Service Coordinator?

Contact the Coordination Support Center of Texas Children’s Health Plan 1-800-659-5764.

How to obtain a named Service Coordinator?

Service Coordinators are case managers who advocate and work with your healthcare team. Your assigned service coordinator ensures you receive timely, high quality, cost effective care and support during both acute and chronic phases of your health. Service coordinators safeguard your health through the creation of an individualized service plan, which includes a holistic evaluation of your physical, behavioral, and social needs.  

Call 1-800-659-5764 to request a named Service Coordinator.

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Health-care billing mistakes happen a lot. The rules that doctors and hospitals must follow are very tricky. Mistakes also happen because the doctor’s office or emergency room is just really busy. Most doctors and hospitals want to do what is right. They want to follow the rules and take care of your family.

But, you may have read about hospitals and providers that have cheated the system. They billed for services they did not do, or worse. We need your help to stop this. Texas Children’s Health Plan has been authorized by the State of Texas to help identify and prevent fraud, abuse, and waste. These terms mean:

  • Fraud-Knowingly submitting false claims in order to receive payment.
  • Abuse-Taking advantage of loopholes in the law to increase payments.
  • Waste-Making excessive payments due to poor training and education.

Fraud, abuse, and waste hurts everyone. It raises taxes. It reduces funds available to pay benefits. It may even reduce the quality of care.

Some examples of fraud you might see include:

  • Providers billing for services your family did not receive.
  • Billing for different services than what you received.
  • Asking for your member ID number when you are not going to the clinic or hospital.
  • Offering money for your member ID number.
  • Offering prizes or payments for you to come to a clinic or hospital.

Be on the lookout for common scams such as:

  • Statements that “Your health plan wants you to have this service.”
  • Telemarketing or door-to-door salespeople offering medical services.
  • Saying that the more tests that are done, the cheaper they are for the government.

To help us prevent fraud, follow these tips:

  • Don’t give out your member ID number to anyone you do not know. Only give it to your doctor or hospital.
  • Don’t ask for services you don’t need.
  • Be careful of anyone saying “The services are free, so you should use my clinic.”

Can members commit fraud?

Some members do commit fraud. They might change doctors to feed a bad habit. They might ask for services they do not need or they may lie to a doctor. Some may even work with a doctor to commit fraud in return for money. Member fraud is against the law. Member fraud could result in losing your benefits. It can also mean fines or jail.

If you suspect fraud, abuse, or waste

What if you suspect fraud? Contact us immediately. Do not wait more than one day.

Texas Children’s Health Plan’s fraud hotline is 1-832-828-1320. The fax number is 1-832-825-8772. You can e-mail us at TCHPSIU@texaschildrens.org.

Or send a letter to:

Texas Children’s Health Plan
Fraud and Abuse Investigations
Mail Code WLS 8360
PO Box 301011
Houston, TX 77230-1011

You do not have to give your name. Just tell us why you think there is fraud. Give us the name of the provider and tell us what you are worried about. We will take your concerns seriously. We will investigate every case. We may even send your concern to the State. Most often, we will teach the provider what they did wrong.

Please help us

Texas Children’s Health Plan wants to identify and prevent fraud. We need, and appreciate, your help! Call us with any questions.