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Provider Complaints and Appeals
Providers may submit appeals in writing or through our Provider Portal at texaschildrenshealthplan.org/for-providers.
All appeals of claims and requests for adjustments must be received by Texas Children’s Health Plan within 120 days from the date of the last denial of and/or adjustment to the original claim.
A Claim Appeal Form must be sent in with an appeal submitted on paper. To submit an appeal on paper, mail or fax the appeal to the following:
Texas Children’s Health Plan
Attention: Claims Administration Department
P.O. Box 300286
Houston, TX 77230-0286
Fax: 1-844-386-3171 (toll free) or 346-232-4710
Texas Children’s Health Plan will process claim appeals and adjudicate the claim within thirty (30) days from the date of receipt of the claim appeal.
Provider Complaints Process to HMO
As a STAR and CHIP health plan, it is the policy of Texas Children’s Health Plan to adhere to State Medicaid Provider Guidelines as defined in the current edition of the Texas Medicaid Provider Procedures Manual. A complaint includes any dissatisfaction with any aspect of Texas Children’s Health Plan’s operations, including plan administration, the appeal of an adverse determination, the denial, reduction, or termination of a service, the way a service is provided, or disenrollment decisions, may file a complaint or appeal with Texas Children’s Health Plan. The following information will assist providers in filing.
How to Submit a Complaint as a Medicaid Provider
Medical Necessity Appeals Requests
Medical Necessity Appeals/Appeals for a requested service
If Texas Children’s Health Plan denies a provider’s request for a service authorization due to medical necessity, a provider has 60 calendar days to request an appeal. To request an appeal, please send your written request to:
Texas Children’s Health Plan
Attention: UM Appeals Department
PO Box 300709 WLS 8390
Houston, TX 77230
Fax: 832-825-8796
To assist Texas Children’s Health Plan in your request, please state the reason you are requesting your appeal and submit supporting medical documentation. Texas Children’s Health Plan will acknowledge in writing your request within 5 business days, and if necessary, request specific medical information to support your appeal. If you do not provide Texas Children’s Health Plan with the requested medical information within 10 days, Texas Children’s Health Plan will make its decision based on the information provided. Texas Children’s Health Plan will respond to your appeal within 30 calendar days.
All appeals of adverse determination for which medical records are not received within 30 calendar days of the filing date will be finalized and the original decision will be upheld. This decision is final and binding, and the provider will have exhausted his/her appeal rights with Texas Children’s Health Plan.
Texas Children’s Health Plan Provider and Care Coordination | 832-828-1008
Expedited Appeals to a Denial for Service Authorization
If Texas Children’s Health Plan denies a request for services and a member’s medical condition may be jeopardized by the standard 30 calendar day appeal timeframe, a provider may request an expedited appeal review. To request an expedited review, please fax the request to 832-825-8796. Texas Children’s Health Plan will respond to expedited appeals involving emergency services or continued hospitalization within 1 business day.
Second Level Appeals to a Denial for Service Authorization
If Texas Children’s Health Plan upholds its decision to deny authorization for requested services due to medical necessity, you have a right to request a second review from a different provider in the same or similar specialty. You must file your request within 30 calendar days from receipt of Texas Children’s Health Plan appeal decision and set forth in writing good cause for having a particular specialty review.
To request a specialty review, please send your request to:
Texas Children’s Health Plan
Attention: Appeals Department
PO Box 300709 NB 8390
Houston, TX 77230
Texas Children’s Health Plan will complete its specialty review within 15 business days from receipt of your request.
Provider Complaints to Texas Health and Human Services Commission
Providers may file complaints to HHSC if they feel they did not receive full due process from Texas Children’s Health Plan. The commission is only responsible for the management of complaints for managed care providers. Appeals/grievances, hearings, or dispute resolution are the responsibility of the Health Plan.
Complaints must be in writing and mailed to:
Texas Health and Human Services Commission
Re: Provider Complaint
Health Plan Operations, H-320
PO Box 85200
Austin, TX 78708
HPM_Complaints@hhsc.state.tx.us