External Medical Review

TCHP follows the guidance on External Medical Review in accordance with the Uniform Managed Care Manual, Chapter 3.21.1 and Senate Bill 1207. The resource document available here outlines the different aspects of this process that are completed by designated Independent Review Organizations (IROs) when there are service denials, reductions, and eligibility denials for certain programs based on medical or functional necessity made by TCHP.

TCHP will ensure that all of the appropriate documentation is uploaded in Texas Integrated Eligibility Redesign System (TIERS) that was included in the service reduction or denial decision. Should the Member, the Member’s authorized representative, or the Member’s LAR decide to withdraw the EMR request, they must initiate an EMR request withdrawal communication to us here at TCHP.

External Medical Review contact information:

STAR Members at 832-828-1001 or toll free at 1-866-959-2555
STAR Kids Members toll free at 1-800-659-5764.

For written requests:

Email TCHPUM@TEXASCHILDRENS.ORG
Fax 832-825-8796 

Texas Children’s Health Plan
Attention: Utilization Management Department
WLS 8390
P.O. Box 301011
Houston, TX 77230-1011

Resources:

• Member Notice of Internal Appeal Decision /State Fair Hearing and External Medical Review Request Form
• Member Notice of Adverse Benefit Determination Form/Health Plan Appeal Request Form