Provider Complaints & Appeals

 

Provider complaints

Dell Children’s Health Plan accepts provider complaints orally, as well as via mail, fax and email. Oral complaints may be submitted through Provider Services at 1-888-821-1108 or through local Provider Relations representatives. Written provider complaints should be mailed to the following address:

Dell Children’s Health Plan
4515 Seton Center Parkway Suite 310
Austin, TX 78759

Written complaints can also be sent to the attention of the Provider Relations department of the local health plan or faxed to 512-380-7547. Complaints may also be sent in a secure email to shpproviderservices@seton.org.

If a provider is not satisfied with the resolution of the complaint by Dell Children’s Health Plan, a complaint may be submitted to the Health and Human Services Commission.

Provider Claim Payment Disputes and Appeals

The information below is a summary of each process. For full details, refer to the provider manual.

Provider claim payment disputes

If you disagree with the outcome of a claim, you may use the Dell Children’s Health Plan provider claim payment dispute process. The simplest way to define a claim payment dispute is when a claim is finalized, but you disagree with the outcome.

The Dell Children’s Health Plan provider claim payment dispute process consists of two internal options. You will not be penalized for filing a claim payment dispute, and no action is required by the member:

  1. Claim payment reconsideration: This is a convenient option in the Dell Children’s Health Plan provider claim payment dispute process. The reconsideration is an initial request for an investigation into the outcome of the claim. Most issues are resolved with a claim payment reconsideration.
  2. Claim payment appeal: This is an additional option in the Dell Children’s Health Plan provider claim payment dispute process. If you disagree with the outcome of a reconsideration or you choose not to ask for a reconsideration, you may request a claim payment appeal. Please note: If you did not ask for a claim payment reconsideration first, this will be the only internal appeal option available for your

Claim payment reconsideration

The first available option in the Dell Children’s Health Plan claim payment dispute process is called the reconsideration. It is your initial request to investigate the outcome of a finalized claim. Please note: We cannot process a reconsideration without a finalized claim on file.

We accept reconsideration requests in writing, verbally or online through the Availity Portal at https://www.availity.com within 120 calendar days from the date on the Explanation of Payment (EOP). See below for further details on how to submit. Reconsiderations filed more than 120 calendar days from the EOP will be considered untimely and denied unless good cause can be established. Dell Children’s Health Plan will resolve the claim payment reconsideration within 30 calendar days of receipt.

Claim payment appeal

If you are dissatisfied with the outcome of a reconsideration determination or wish to bypass the reconsideration process altogether, you may submit a claim payment appeal. We accept claim payment appeals online through the Availity Portal at https://www.availity.com or in writing within the later of:

  • 30 calendar days from the date on the reconsideration determination letter, or
  • 120 calendar days from the date of the original EOP

Claim payment appeals received later than these timeframes will be considered untimely and upheld unless good cause can be established. Dell Children’s Health Plan will resolve the claim payment appeal within 30 calendar days of receipt.

How to submit a claim payment dispute

You have several options to file a claim payment dispute:

  • Online (for reconsiderations and claim payment appeals): Use the secure Availity Provider Payment Appeal Tool at https://www.availity.com. Through the Availity Portal, you can upload supporting documentation and will receive immediate acknowledgement of your
  • Verbally (for reconsiderations only): Call Provider Services at 1-888-821-1108.
  • Written (for reconsiderations and claim payment appeals): Mail all required documentation, including the Provider Payment Dispute and Correspondence Submission Form, to:

Payment Dispute Unit
Dell Children’s Health Plan
P.O. Box 61599 Virginia Beach, VA 23466-1599

  • Fax (for reconsiderations and claim payment appeals) all required documentation to 1-844-756-4607.

Provider medical appeals

This type of appeal is available to providers with respect to a denial of services that have already been provided to the member and determined to be not medically necessary or appropriate. These appeals do not include member medical necessity appeals. Provider medical appeals should be submitted in writing to:

Appeals Team
Dell Children’s Health Plan
P.O. Box 61599
Virginia Beach, VA 23466-1599

A provider must file a medical appeal within 120 calendar days of the date of the denial letter or EOP. The results of the review will be communicated in a written decision to the provider within 30 calendar days of our receipt of the appeal.

If a provider is dissatisfied with the appeal resolution, he or she may file a second-level appeal. This must be a written appeal submitted within 30 calendar days of the date of the first-level determination letter. The case is handled by reviewers not involved in the first-level review. The results of the review are communicated in a written decision to the provider within 30 calendar days of receipt of the appeal.

Provider appeal process to Texas Health and Human Services Commission (HHSC) (related to claim recoupment due to member disenrollment)

A provider may appeal claim recoupment by submitting the following information to HHSC:

  • A letter indicating that the appeal is related to a managed care disenrollment/recoupment and that the provider is requesting an exception request.
  • The explanation of benefits (EOB) showing the original payment. Note: This is also used when issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an authorization for the exact items that were approved by the plan.
  • The EOB showing the recoupment and/or the plan’s demand letter for recoupment. If sending the demand letter, it must identify the client name, identification number, date of service and recoupment amount. The information should match the payment EOB.
  • Completed, clean claim. All paper claims must include both a valid NPI and TPI number. Note: In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted with the authorization number, and the provider will need to submit a corrected claim that contains the valid authorization number.

Mail HHSC recoupment appeal requests to the following address:

Texas Health and Human Services Commission
Claims Administrator Contract Management
Mail Code 91X P.O. Box 204077
Austin, Texas 78720-4077