Filing complaints and appeals in Texas

Complaints

 

If you're unhappy about a decision we made or care you received, you have the right to file a complaint. A Wellpoint Member Services representative or a member advocate can help you.

 

How to file a complaint

You have two ways to tell us about your complaint:

 

Call Member Services toll-free at 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711).

 

Mail a letter or complaint form to: (STAR Kids Members, use this form complaint form)

 

Member Advocates
Wellpoint
2505 N. Highway 360, Suite 300
Grand Prairie, TX 75050

 

After you file a complaint

We'll send you a letter within five business days of getting your complaint. It will tell you we received your complaint and are taking the appropriate next steps. If your complaint was made by phone, the letter will include a complaint form. You must fill this out and mail it back to us at the address above. If you need help filling out the form, please call Member Services.

 

We'll send you another letter within 30 days of getting your complaint. The letter will tell you what we've done to address it.

 

If your complaint is about an ongoing emergency or hospital stay, it will be resolved as quickly as needed for the urgency of your case and no later than one business day from when we receive it.

 

Call Member Services at 833-731-2160 (TTY 711) for status updates on your complaint or questions about the complaint process. STAR Kids members, call 844-756-4600 (TTY 711).

 

If you're not happy with our answer to your complaint, you can get more help from the Texas Health and Human Services Commission.

 

STAR, STAR+PLUS, and STAR Kids members

If you get benefits through Medicaid's STAR, STAR+PLUS, 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 the Medicaid Managed Care Helpline toll-free at 866-566-8989.

 

Submit an online form.

 

Mail a letter to:

 

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

 

Fax a letter toll-free to 888-780-8099.

 

CHIP and CHIP Perinate members

Submit complaints to the Texas Department of Insurance by doing one of the following:

 

Call 800-252-3439.

 

Mail a letter to:

 

Consumer Protection, MC: CO-CP
Texas Department of Insurance
PO Box 12030
Austin, TX 78711-2030

 

Submit an online form.

 

Your decision to file a complaint won't affect your ability to access quality care.

Appeals

 

STAR, STAR+PLUS, and STAR Kids members

Sometimes, we make decisions about care and services you or your provider asks for. When we decide to deny or reduce a service, you may ask for an appeal. During an appeal, a doctor or other qualified reviewer not involved in the original decision, looks again at your case. He or she will review all the information about your appeal and make an appeal decision.

 

How to request an internal appeal

You must ask for an appeal within 60 calendar days of the date on the decision letter. You can also ask your provider or another person to appeal for you.

 

You can appeal in several ways:

 

Send a letter or a Medicaid appeal request English / Spanish form by mail or fax to:

 

Wellpoint Appeals
PO Box 62429
Virginia Beach, VA 23466-2429
Fax: 877-881-1305

 

Call Member Services at 833-731-2160 (TTY 711).
STAR Kids members, call 844-756-4600 (TTY 711). Tell us you want to file an appeal.

 

After you request an appeal

We'll send you a letter with our appeal decision within 30 calendar days of getting your request.

 

If your appeal involves services we previously approved and are now reducing or ending, you may be able to keep getting those services while your appeal is being reviewed. To do so, you must file the appeal before the later of the two dates below:

 

Ten calendar days after the date we send you the denial notice, or

 

The day our letter says your service will end or be reduced.

 

If we uphold our first decision, you may have to pay for the services you received during the appeal process.

 

Call Member Services at 833-731-2160 (TTY 711) for status updates on your appeal or questions about the appeal process. STAR Kids members, call 844-756-4600 (TTY 711).

 

Learn more about the appeal process, including emergency appeals for emergency or life-threatening situations, by reading the member handbook.

 

How to request an External Medical Review and State Fair Hearing

If you disagree with our internal appeal decision, you have the right to ask for an External Medical Review from an Independent Review Organization and a State Fair Hearing from the Texas Health and Human Services Commission (HHSC). There are no fees for these reviews. You must request an External Medical Review and State Fair Hearing within 120 calendar days of the date on our appeal decision letter. If you don't get an appeal decision within the required time frame, you can ask for an External Medical Review and State Fair Hearing without getting our appeal decision.

 

You can ask for an emergency External Medical Review and State Fair Hearing due to an emergency or life-threatening situation, but you must complete our internal appeal process.

 

You can ask for an External Medical Review and State Fair Hearing by:

 

Calling Member Services at 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711).

 

Mailing or faxing a letter or a State Fair Hearing and External Medical Request English / Spanish form to:

 

Wellpoint Fair Hearing Coordinator
PO Box 62429
Virginia Beach, VA 23466-2429
Fax: 855-883-9039

 

If you ask for an External Medical Review and State Fair Hearing within 10 days from the date we sent the appeal decision letter, you may be able to keep getting the service or benefit we denied or reduced if you kept receiving the services during the internal appeal process, at least until the final hearing decision is made. If the State Fair Hearing upholds our decision to deny or reduce services, you may have to pay for any services you kept receiving.

 

If you ask for a State Fair Hearing, we'll send you a packet of information telling you the date, time, and location of the hearing. Most State Fair Hearings are held by telephone, so you won't need to attend in person. HHSC will give you a final decision within 90 calendar days from the date you asked for the hearing. If you have any questions during the process, please call Member Services at 833-731-2160 (TTY 711). STAR Kids members, call 844-756-4600 (TTY 711).

 

You can ask for a State Fair Hearing without an External Medical Review. The request process is the same as described above for requesting both. An External Medical Review cannot be requested without a State Fair Hearing, but you can withdraw your request for the hearing after you get the External Medical Review decision.

 

Call Member Services at 833-731-2160 (TTY 711) for status updates on your External Medical Review or State Fair Hearing or questions about the process. STAR Kids members, call 844-756-4600 (TTY 711).

 

Your decision to ask for an internal appeal or State Fair Hearing with or without an External Medical Review won't affect your ability to access quality care.

 

CHIP and CHIP Perinate members

If we tell you we won't pay for all or part of the care your doctor recommended, you can appeal. An appeal is when you ask us to look again at the care we said we won't pay for.

 

How to request an appeal

You must submit your appeal within 60 days of the date on our first denial letter. You can also ask your doctor or another person to appeal for you.

 

You can appeal in two ways:

 

Call Member Services at 833-731-2160 (TTY 711)

 

Send a letter or a Medical Appeal Form to:

 

Wellpoint Appeals
PO Box 62429
Virginia Beach, VA 23466-2429

 

After you request an appeal

We'll send you a letter with the answer to your appeal. We'll do this within 30 calendar days from the time we get your appeal. The only exceptions are for urgent and other appeals that need a quicker decision.

 

If you don't agree with our decision, your provider can send us a letter to ask for a specialty review if it was not part of your appeal. This letter must be sent to us within 10 business days from the date on our letter with the answer to your appeal. A provider who specializes in the type of care your child’s provider asked for will review your case. We’ll tell you and your provider our decision within 15 business days from when we receive the specialty review appeal request.

 

Call Member Services at 833-731-2160 (TTY 711) for status updates on your appeal or questions about the appeal process.

 

You can ask for an independent external review after either your first appeal or a specialty review.

 

How to request an independent external review

If we still won’t pay for care after a first level appeal or a specialty review, and the decision involved medical judgment, you can ask for an external review by an independent third party within four months of getting the appeal decision. MAXIMUS Federal Services, Inc. is the independent review organization that will conduct the external review. Our decision letter and the member handbook tell you how to ask for this kind of review. One way is to send an HHS-Administered Federal External Review Request Form in English or Spanish.

 

Complete and sign the form. Then, fax it to 888-866-6190 or mail it to:

 

MAXIMUS Federal Services
3750 Monroe Ave., Suite 705
Pittsford, NY 14534

 

You can also submit your external review request online at externalappeal.cms.gov under the Request a Review Online heading.

 

If you have questions about the external appeal process or how to submit a request, call Member Services at 833-731-2160 (TTY 711). After you submit a request, you can also contact MAXIMUS at 888-866-6205 or go to externalappeal.cms.gov

 

Your decision to file an appeal or ask for an independent review won't affect your ability to get quality health care.

 

To learn more about the appeal process, expedited appeals, specialty reviews, and independent external reviews, read the member handbook.

 

Visit Member Materials to read the CHIP member handbooks.