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Evidence of Coverage

You can get a printed copy of this handbook at no cost. We can also give this to you in other formats or other languages at no cost if you need it.

We can even provide interpreters to help you better understand your plan if you need them. To get this support, call our Member Services team.

• CHIP: 1-866-959-6555
• STAR: 1-866-959-2555
• STAR Kids: 1-800-659-5764

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 Provider" tool. 

For more information visit www.TXHealthSteps.com 

You can request a new Member ID card by calling our Member Service team at the numbers below.

• CHIP: 1-866-959-6555
• STAR: 1-866-959-2555
• STAR Kids: 1-800-659-5764

Do you have thoughts or ideas that can help Texas Children’s Health Plan improve? We want to hear them!

Our Member Advisory Group (MAG) gives members a chance to tell us how we are doing, ask questions, and share ideas on how we can do better. MAG meeting participants include Texas Children’s Health Plan members, staff, and community partners. We value your opinion and are committed to providing you with the best quality of care.

You’re invited!

Your feedback is important to us! Join our upcoming virtual MAG meeting and receive a $10 gift card for attending! As a member or parent, you are welcome to attend at no cost!

Member Advisory Group (MAG) Registration

Topics will include:

• Texas Children’s Health Plan’s services, programs, and events.
• Discuss and review member materials.
• Improvement opportunities for all areas of the health plan.
• Community Resources

Read your rights and responsibilities

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

Keep up on notices from the state and from Texas Children’s Heath Plan. 

Learn more about Prior authorization.

How to file a Complaint 

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)

• If you are not happy with your health care or services provided by your doctor, their office staff, or the Texas Children’s Health Plan staff, you can file a complaint. Read more.

Appeals 

• You can also file an appeal of an action made by Texas Children’s Health Plan. Read more.

State Fair Hearing  

• A State Fair Hearing is a chance for you to tell the reasons why you think the services you asked for, but did not get, should be allowed. Read more.

External Medical Review  

• If you, as a member of the health plan, disagree with our internal appeal decision, you can ask for an External Medical Review. Read more. 

Fraud and Abuse

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.