Complaints and Appeals Process

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. If you call us, you must still send us your appeal in writing as well. We will send you an appeal form in the mail after your call. Fill out the appeal form and send it to us within 60 days of the date of the letter telling you we were denying your request to:
  • Dell Children’s Health Plan Appeals
    2505 N. Highway 360, Suite 300
    Grand Prairie, TX 75050

The appeal form must be signed by you or your authorized representative. If you need help filling out the appeal form, please call Member Services at 888-596-0268.

  1. You can send us a letter to:
  • Dell Children’s Health Plan Appeals
    2505 N. Highway 360, Suite 300
    Grand Prairie, TX 75050

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. 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. 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.

Medicaid Appeals Process

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 888-596-0268 (TTY 711).

Can members request a state fair hearing?

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 888-596-0268 TTY 711 for any questions about the process or the status of your complaints and/or appeals.

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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/ specialty review. Your child’s provider must send us a letter to ask for a second level appeal/specialty review 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/specialty review. A doctor who specializes in the type of care your provider says your child needs will look at the case. We will send you a letter with this doctor’s decision within 15 business days. This letter is our final decision. If you do not agree with our decision you may request an independent review form by calling 888-596-0268. 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 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.

Where can I send written requests?

You can mail any written requests to:
Dell Children’s Health Plan Appeals
2505 N. Highway 360
Suite 300
Grand Prairie, TX 75050

Does my request have to be in writing?

No. You can request an appeal by calling Member Services at 888-596-0268 TTY 711.

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

You can call Member Services at 888-596-0268 TTY 711 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 your Member Services Representative at 888-596-0268 TTY 711 for any questions about the process or the status of your complaints and/or appeals.

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Medicaid Fair Hearing Process

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 Request form to the health plan at:

  • Fair Hearing Coordinator
    Dell Children’s Health Plan
    5959 Corporate Drive, Suite 1300
    Houston, TX 77036

Or you can call Member Services at 888-596-0268 (TTY 711). 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 Medicaid 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.

If you have any questions during the process, please call Member Services at 1-888-596-0268 (TTY 711).

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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 888-596-0268 (TTY 711) 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 888-596-0268 (TTY 711) and ask to be referred to the 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
2505 N. Highway 360
Suite 300
Grand Prairie, TX 75050

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 form or letter. 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. If you want to file a verbal complaint, contact Member Services at 888-596-0268 (TTY 711).

Who Do I Call for Process or Status Questions?

You may contact your Member Services Representative at 888-596-0268 TTY 711 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?

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 and they can help you file an appeal. If you receive benefits through Medicaid’s STAR, program, call your medical plan first. If you don’t get the help you need there, you should do one of the following:
a. Call Medicaid Managed Care Helpline at 866-566-8989 (toll free).
b. Online: Online Submission Form (only works in Internet Explorer)
c. Mail: Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
d. Fax: 888-780-8099 (Toll-Free)

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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.

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. If the complaint was received orally, we will enclose a one-page complaint form clearly stating that the complaint form must be returned to us for prompt resolution.

After receipt of the written complaint or one-page complaint form from you, 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.

To obtain information or make a complaint:Para obtener información o para someter una
queja:
You may contact your Member Services
Representative at 1-888-596-0268 TTY 711.
Puede comunicarse con su Representante de
Servicios a los Miembros al 1-888-596-0268 TTY
711.
You may call the Dell Children’s Health Plan toll-free
telephone number for information or to make a
complaint at 1-888-596-0268 TTY 711.
Usted puede llamar al número de teléfono gratis
de Dell Children’s Health Plan para información
o para someter una queja al 1-888-596-0268
TTY 711.
You may also write to:
Dell Children’s Health Plan Appeals
2505 N. Highway 360
Suite 300
Grand Prairie, TX 75050
Usted también puede escribir a:
Dell Children’s Health Plan Appeals
2505 N. Highway 360
Suite 300
Grand Prairie, TX 75050
You may contact the Texas Department of Insurance
to obtain information on companies, coverages, rights,
or complaints at 1-800-252-3439.
Puede comunicarse con el Departamento de
Seguros de Texas para obtener información
acerca de compañías, coberturas, derechos o
quejas al 1-800-252-3439.
You may write the Texas Department of Insurance at:

PO Box 149104
Austin, TX 78714-9104
FAX #: 512-475-1771
Web: www.tdi.state.tx.us
Email: consumerprotection@tdi.state.tx.us
Puede escribir al Departamento de Seguros de
Texas:
PO Box 149104
Austin, TX 78714-9104
FAX #: 512-475-1771
WEB: www.tdi.state.tx.us
EMAIL: consumerprotection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: Should you have a
dispute concerning YOUR premium or about a claim
you should contact the (agent) (company) (agent or
the company) first. If the dispute is not resolved, you
may contact the Texas Department of Insurance.
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene
una disputa concerniente a su prima o a un
reclamo, debe comunicarse con el (agente) (la
compañía) (agente o la compañía) primero. So
no se resuelve la disputa, puede entonces
comunicarse con el departamento (TDI).
ATTACH THIS NOTICE TO YOUR POLICY: This notice is
for information only and does not become a part or
condition of the attached document.
UNA ESTE AVISO A SU POLIZA:
Este aviso es solo para propósito de información
y no se convierte en parte o condición del
documento adjunto.

Who Do I Call for Process or Status Questions?

You may contact your Member Services Representative at 888-596-0268 TTY 711 for any questions about the process or the status of your complaints and/or appeals.

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