Complaints and Appeals Process

STAR Medicaid complaint process

What should I do if I have a complaint? Who do I call?

We want to help. If you have a complaint, please call Member Services at 1-855-921-6284 (TTY 7-1-1) to tell us about your problem.

Can someone from Dell Children’s Health Plan help me file a complaint?

Yes. A Dell Children’s Health Plan Member Advocate can help you file a complaint with Dell Children’s Health Plan or with the appropriate state program. Just call 1-855-921-6284 (TTY 7-1-1) and ask to talk to a Dell Children’s Health Plan member advocate. Most of the time, we can help you right away or at the most within a few days. You can also send a letter to Dell Children’s Health Plan to tell us about your problem.

Send the letter to:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723.

How long will it take to process my complaint?

Dell Children’s Health Plan will send you a letter within 5 business days of receiving your complaint. We will then look into the issue. We will resolve the complaint within 30 days of receiving it, and notify you by mail.

What are the requirements and timeframes for filing a complaint?

You can file a complaint at any time. You do not have to wait to file a complaint.

Who do I call for process or status questions?

You may contact Member Services at 1-855-921-6284 (TTY 7-1-1) for any questions about the process or the status of your complaints and/or appeals.

If I am not satisfied with the outcome of my complaint, can I file an appeal?

Once you have gone through the Dell Children’s Health Plan complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989.

If you would like to make your Complaint in writing, please send it to the following address:

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247

If you can get on the Internet, you can submit your complaint at:

hhs.texas.gov/managed-care-help

If you do not feel Dell Children’s Health Plan gave you the right answer for your complaint, you can appeal the decision. Call Member Services at 1-855-921-6284 (TTY 7-1-1) and they can help you file an appeal. If you receive benefits through Medicaid’s STAR program, call your health 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: Online Submission Form
  • 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)

STAR Medicaid appeals process

What can I do if my doctor asks for a service for me that’s covered but Dell Children’s Health Plan denies or limits it?

There may be times when Dell Children’s Health Plan says it will not pay for or cover all or part of the care that has been recommended. You have the right to ask for an appeal. An appeal is when you or your designated representative asks Dell Children’s Health Plan to look again at the care your doctor asked for and we said we will not pay for.

You can appeal our decision in 2 ways:

  1. You can call Member Services at 1-855-921-6284
  1. You can send us a letter to:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723.

How will I find out if services are denied?

If we deny coverage, we will send you a letter.

What are the time frames for the appeals process?

You or a designated representative can file an appeal. You must do this within 60 days of the date of the first letter from Dell Children’s Health Plan that says we will not pay for or cover all or part of the care that has been recommended.

When we get your letter or call, we will send you a letter within 5 business days. This letter will let you know we got your appeal. We will also let you know if we need any other information to process your appeal. Dell Children’s Health Plan will contact your doctor if we need medical information about this service.

If you ask someone (a designated representative) to file an appeal for you, you must also send a letter to Dell Children’s Health Plan to let us know you have chosen a person to represent you.

Dell Children’s Health Plan must have this written letter to be able to consider this person as your representative. We do this for your privacy and security.

A doctor who has not seen your case before will look at your appeal. He or she will decide how we should handle your appeal. We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal unless we need more information from you or the person you asked to file the appeal for you. If we need more information, we may extend the appeals process for 14 days. If we extend the appeals process, we will let you know the reason for the delay. You may also ask us to extend the process if you know more information that we should consider.

How can I continue receiving my services that were already approved?

To continue receiving services that have already been approved by Dell Children’s Health Plan but may be part of the reason for your appeal, you must file the appeal on or before the later of:

  • 10 business days after we mail the notice to you to let you know we will not pay for or cover all or part of the care that has already been approved
  • The date the notice says your service will end

If you request that services continue while your appeal is pending, you need to know that you may have to pay for these services.

If the decision on your appeal upholds our first decision, you may be asked to pay for the services you received during the appeals process.

If the decision on your appeal reverses our first decision, Dell Children’s Health Plan will pay for the services you received while your appeal was pending.

Can someone from Dell Children’s Health Plan help me file an appeal?

Yes, a member advocate or Member Services representative can help you file an appeal.

Please call Member Services toll-free at 1-855-921-6284 (TTY 7-1-1).

Can members request a state fair hearing with or without external medical review?

Yes, you can ask for a fair hearing after the Dell Children’s Health Plan appeal process. See the state fair hearings section below for more information.

Who do I call for process or status questions?

You may contact your member services representative at 1-855-921-6284 (TTY 7-1-1) for any questions about the process or the status of your complaints and/or appeals.

State fair hearing and external medical review requests

Can I ask for a state fair hearing?

If you, as a member of the 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 your health plan, you or your representative must ask for the fair hearing within 120 days of the date on the health plan’s letter with the appeal decision. If you do not ask for the fair hearing within 120 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter or a State Fair Hearing form to the health plan at:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723.

Or you can call Member Services at 1-855-921-6284 (TTY 7-1-1). We can help you with this request.

You have the right to keep getting any service the health plan denied or reduced; at least until the final hearing decision is made, if you ask for a fair hearing by the later of:

  • 10 calendar days following the Dell Children’s Health Plan mailing of the notice of the action or
  • The day the health plan’s letter says your service will be reduced or end

If you do not request a fair hearing by this date, the service the health plan denied will be stopped.

If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.

Can I ask for an emergency State Fair Hearing?

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

Can I 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:

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 Dell Children’s Health Plan 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

If you have any questions during the process, please call Member Services at 1-855-921-6284 (TTY 7-1-1).

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 Dell Children’s Health Plan.

To qualify for an emergency External Medical Review and emergency State Fair Hearing review through HHSC, you must first complete Dell Children’s Health Plan’s internal appeals process.

CHIP complaint process

Complaint means any dissatisfaction expressed by you orally or in writing to us with any aspect of our operation, including but not limited to, dissatisfaction with plan administration; procedures related to review or appeal of an adverse determination; the denial, reduction, or termination of a service for reasons not related to medical necessity; the way a service is provided; or dis-enrollment decisions.

Filing a complaint

If you are not satisfied with the way we handled the request for services for your child or your appeal, you, your provider, or someone acting on your behalf can file a complaint against Dell Children’s Health Plan. A complaint about our decision not to pay for a service your child needs is considered an appeal and will follow the appeal process outlined above.

To file a complaint, call us at 1-855-921-6284. (TTY 7-1-1). You can also send us a letter telling us about your complaint. Send the letter to:

Member Advocate
Dell Children’s Health Plan
1345 Philomena St., St. 305
Austin, TX 78723

In your letter or call, tell us why you are dissatisfied with the way we handled the request for services for your child or our appeals process. You can tell us what you’re unhappy with such as:

  • The way we served or treated you
  • The way the appeals process works
  • How long it took us to make a decision

We’ll send you a letter telling you we got your complaint within 5 business days from the date of your complaint.

We’ll look into your complaint and mail our answer to you no later than 30 calendar days from the date we received your written complaint or completed Member Complaint Form. Our letter will also tell you how we resolved your complaint.

If your complaint is for an emergency or denial of continued stay for hospitalization, it will be resolved:

  • According to the medical or dental urgency of your case.
  • No later than 1 business day from the date we receive your complaint.

Filing a complaint with the Texas Department of Insurance

You, your provider, or a person acting on your behalf can file a complaint with the Texas Department of Insurance at any time. To file a complaint, you can:

  • Call 1-800-252-3439.
  • Send a letter to:
    Texas Department of Insurance
    Consumer Protection Section
    Mail Code 111-1A
    PO Box 149091
    Austin, TX 78714-9091
  • Follow the instructions online at www.tdi.texas.gov/consumer/complfrm.html.

How to get a copy of our records of your complaint

You can get a copy of our records about your complaint and any related proceeding. Call us at 1-855-921-6284 (TTY 7-1-1) to request a copy.

If you notify us orally or in writing of a complaint, we will, not later than the 5th business day after the date of the receipt of the complaint, send to you a letter acknowledging the date we received your complaint.

We will investigate and send you a letter with our resolution. The total time for acknowledging, investigating, and resolving your complaint will not exceed 30 calendar days after the date we receive your complaint.

Your complaint concerning an emergency or denial of continued stay for hospitalization will be resolved in 1 business day of receipt of your complaint. The investigation and resolution shall be concluded in accordance with the medical immediacy of the case.

You may use the appeals process to resolve a dispute regarding the resolution of your complaint.

Once you have gone through the Dell Children’s Health Plan complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989. If you would like to make your Complaint in writing, please send it to the following address:

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247

If you can get on the Internet, you can submit your complaint at hhs.texas.gov/managed-care-help.

CHIP appeals process

What can I do if my child’s provider asks for a service for my child that is covered but Dell Children’s Health Plan denies or limits it?

There may be times when Dell Children’s Health Plan says it will not pay for care that has been recommended by your provider. If we do this, you, the person acting on your behalf or your child’s provider can appeal the decision. An appeal is when you ask Dell Children’s Health Plan to look again at the care your child’s provider asked for and we said we will not pay for. You must file for an appeal within 30 days from the date on our first letter that says we will not pay for a service.

How will I find out if services are denied?

You will receive a letter if you have services that are denied.

What are the time frames for the appeal process?

When we get your letter or call, we will send you a letter within 5 business days. This letter will let you know we got your appeal. A doctor who has not seen your case before will look at your appeal. He or she will decide how we should handle your appeal.

We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal. We have a process to answer your appeal quickly if the care your provider says your child needs is urgent.

If you are not happy with the answer to your first level appeal, you can ask your child’s doctor to ask us to look at the appeal again. This is called a second level appeal. Your child’s provider must send us a letter to ask for a second level appeal within 10 business days of the date on the first level appeal letter from Dell Children’s Health Plan.

When we get the letter asking for the appeal, we will send you a letter within 5 business days. This letter will let you know we got the letter asking for a second level appeal. A provider who specializes in the type of care your child’s provider asked for will look at your case. We’ll tell you our decision within 15 business days from when we receive the specialty review appeal request from your child’s provider. This letter is our final decision. If you do not agree with our decision you may request an independent review form by calling 1-855-921-6284. We will send you a form to fill out.

When do I have the right to ask for an appeal?

You must request an appeal within 60 days from the date on the first letter from Dell Children’s Health Plan that says we will not pay for the service. If you, the person acting on your behalf, or the provider are not happy with the answer to your first level appeal, the provider must send us a letter to ask for a second level appeal/specialty review. This letter must be sent within 10 business days from the date on our letter with the answer to your first level appeal.

If you file an appeal, Dell Children’s Health Plan will not hold it against you. We will still be here to help you get quality health care.

Where can I send written requests?

You can mail any written requests to:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723.

Does my request have to be in writing?

No. You can request an appeal by calling Member Services at 1-855-921-6284 (TTY 7-1-1).

Can someone from Dell Children’s Health Plan help me file an appeal?

You can call Member Services at 1-855-921-6284 (TTY 7-1-1) if you need help filing an appeal. If you file a medical appeal, Dell Children’s Health Plan will not hold it against you. We will still be here to help you get quality health care.

Who Do I call for process or status questions?

You may contact member services at 1-855-921-6284 (TTY 7-1-1) for any questions about the process or the status of your complaints and/or appeals.

What is an emergency appeal?

An emergency appeal is when the health plan has to make a decision quickly based on the condition of your health and taking the time for a standard appeal could jeopardize your life or health.