HEALTHfirst STAR Medicaid Member Complaints & Appeals

HEALTHfirst STAR Medicaid Member Complaints & Appeals

If you believe you have been discriminated against, your rights have been violated, or the wrong decision was made, you have options.

If you have a problem with your medical care or services, you have a right to file a complaint. A complaint can be filed when you are unhappy with your care. Some examples are:

  • The care you get from your doctor
  • The time it takes to get an appointment or be seen by a doctor
  • The doctors you can choose for care

What is an appeal? A request for your managed care organization to review a denial or a grievance again.

You have the right to ask for an appeal if you are not happy or disagree with an Adverse Benefit Determination. An Adverse Benefit Determination means the denial or limited authorization of a requested service. It includes:

  • the denial in whole or part of payment for a service
  • the denial of a type or level of service
  • the reduction, suspension, or termination of a previously authorized service

You can submit a complaint online through our Member Portal.

Parkland HEALTHfirst’s Member Advocate can help you file a complaint. Call 1-888-672-2277 (TTY 1-800-735-2989) to have a Member Advocate write down your complaint. You can also mail a written complaint to:

Parkland Community Health Plan
Attention: Member Advocate
P. O. Box 560347
Dallas, TX 75356

Be sure to include the following:

  • Member's first and last name
  • ID number (on the front of the Member ID card)
  • Member's address and telephone number
  • Explain the problem

Once you have gone through the Parkland HEALTHfirst 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 have internet, you can submit your complaint at hhs.texas.gov/managed-care-help.

What are the requirements and timeframes for filing a complaint?

The member or provider can file a complaint anytime. The complaint can be oral or in writing. If the complaint is oral, a complaint form will be sent out to the member for a signature.

An acknowledgement letter will be sent to the member within the first 5 business days of receipt of the complaint. A resolution to a complaint will be no longer than 30 calendar days.

Do I have a right to meet with a complaint appeal panel?

Within 5 business days of getting your request for an appeal of a complaint, the Member Advocate will send you a letter to let you know that your complaint appeal came to us.

The Complaint Appeal Panel will look over the information you sent us and discuss your case. It is not a court of law. You have the right to appear in front of the Complaint Appeal Panel at a specific place to talk about the written complaint appeal you sent to us. When we make the decision on your appeal, we will send you a response in writing within 30 calendar days after we receive your appeal.

Need more help?

If you receive benefits through Medicaid’s STAR program, call your medical or dental plan first. Once you have gone through the Parkland HEALTHfirst complaint process, if you didn’t get the help you need there, you should do one of the following:

  1. Call the Medicaid Managed Care Helpline at 1-866-566-8989 (toll-free).
  2. Online: hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman
  3. Mail: Texas Health and Human Services Commission Office of the Ombudsman, MC H-700, P.O. Box 13247 Austin, TX, 78711-3247
  4. Fax: 1-888-780-8099 (toll-free)

You can submit an appeal online on our Member Portal.

Parkland HEALTHfirst’s Member Advocate can help you file an appeal. Call 1-888-672-2277 (TTY English 1-800-735-2989) to have a Member Advocate write down your appeal. You can also mail a written appeal to:

Parkland Community Health Plan
Attention: Member Advocate
P.O. Box 560347
Dallas, TX 75356

How will I find out if services are denied?

If your service or claim is denied, you will get a letter from Parkland Community Health Plan telling you about this decision. It will tell you about your right to appeal. You can also read about these rights in your Member Handbook.

What are the timeframes for the appeal process?

Your request for an appeal of denied or limited services including medication covered by Parkland HEALTHfirst must be filed within 60 calendar days from the date of the decision letter.

To ensure continuity of currently authorized services, you must file the appeal on or before the later of 10 days following Parkland HEALTHfirst mailing of the notice of the action or the intended start date of the proposed adverse benefit determination.

Your request for an appeal can be verbal or in writing. If the appeal is received verbally, the Member Advocate will write down the information and send it to you for review and confirmation. You will need to return the form to the Member Advocate.

A written request can be sent to:

Parkland Community Health Plan
Attention: Member Advocate
P.O. Box 560347
Dallas, TX 75356

The resolution of your appeal can be extended up to 14 calendar days of the appeal if you ask for more time, or if Parkland HEALTHfirst can show that we need more information. We can only do this if more time will help you. We will send you a letter telling you why we asked for more time.

In some cases you have the right to receive an expedited decision. If you are in the hospital or experiencing a medical emergency that is being limited or denied, you can call and ask for an expedited appeal.

Does my request have to be in writing?

Your request does not have to be in writing. You can ask for an expedited appeal by calling the Member Advocate.

What are the timeframes for an expedited appeal?

The timeframe for resolution will be based on your medical emergency condition, procedure, or treatment. Parkland HEALTHfirst will let you know the final decision of the expedited appeal in writing within 24 hours.

What happens if Parkland HEALTHfirst denies the request for an expedited appeal?

If you ask for an expedited appeal that does not involve an emergency, an ongoing hospitalization, or services that are already being provided, you will be told that the appeal cannot be rushed. We will continue to work on the appeal within the standard timeframe and respond to you within 30 days from the time the appeal was received.

A state fair hearing is when the Texas Health and Human Services Commission (HHSC) directly reviews our decisions with your medical care.

You can also ask for an external medical review where independent healthcare experts review your request to receive services. This review is an optional, extra step you can take to get your case reviewed for free before your state fair hearing. It doesn’t change your right to a state fair hearing. 

Request a state fair hearing and external medical review by either:

Going in person to a local HHSC office. You must make a request for a state fair hearing with or without an external medical review by <date 120 Days from the date this notice is mailed>.  

If you don’t ask for the state fair hearing with or without an external medical review by this date, you may lose your right to a state fair hearing. If you have a good reason, like receiving our notice late, we may be able to accept your appeal request after this date.

If you kept receiving services during your health plan appeal, you may be able to continue your services during the State Fair Hearing.

Make a request to continue getting services by <date 10 days from the date this notice is mailed> only if you got services during your health plan  appeal. If you don’t ask for a state fair hearing and to keep your services by then, you will not continue to get your services, but you still have until <date 120 days from the date this notice is mailed> to ask for a state fair hearing with or without the an external medical review.

To make the request call us or check “Yes” on the State Fair Hearing and External Medical Request Form where it says, “Do You Want Your Services to Continue?”

If you lose your state fair hearing, you may have to pay your health plan back for services provided to you during the fair hearing process. Parkland Community Health Plan cannot ask you to pay them back for services you received without permission from HHSC.

What to Expect After You Request a State Fair Hearing

When you ask for a state fair hearing with or without an external medical review, a hearings officer will be placed in charge of your case.

You’ll get a Notice of Hearing in the mail within 10 calendar days of your request for a state fair hearing. It will tell you the date, time, and location of your hearing.

If you ask for an external medical review, it will happen before your state fair hearing. An external medical review doesn’t affect when your state fair hearing will be scheduled.

 

About the External Medical Review
  • HHSC will give your information to independent healthcare experts who will review your case.
  • Only the information submitted for your health plan appeal will be used. You won’t be able to give new information for the review.
  • The experts can agree with or change our decision. Their external medical review decision will be mailed to you in 15 calendar days or less.
  • After you get your external medical review decision, you can choose if you want to also have the state fair hearing you requested.
  • If you want to have your state fair hearing, the external medical review decision will be considered as evidence during your state fair hearing.

 

About the State Fair Hearing
  • Most hearings are held by phone, but if you have a good reason, you can request to hold it in person.
  • You have the right to see any information your health plan will use at the hearing. We’re required to send you this information within 10 calendar days from the date you requested a hearing.
  • You can submit new facts about your case to HHSC. This information will be shared with your health plan prior to the State Fair Hearing.
  • HHSC can agree with or change our decision in a state fair hearing decision. But, if you had an external medical review, the state fair hearing decision will not reduce your benefits below the external medical review decision.
  • The written state fair hearing decision will be mailed to you within 90 calendar days of the date you asked for a state fair hearing.
  • The decision will explain your right to have the case reviewed by an HHSC attorney if you disagree with the decision made about your services.