TMPPM 2011 > Volume 1, General Information > Section 8: Managed Care > PCCM > Provider Complaints and Appeals > Provider Complaints

8.6.20.2.3 Complaints to HHSC-PCCM

PCCM providers may file complaints to HHSC Claims Administrator Contract Management if they find they did not receive full due process from TMHP in the management of their appeal. PCCM providers must exhaust the appeals and grievance process with TMHP before filing a complaint with HHSC Claims Administrator Contract Management.

Refer to: Subsection 7.3, "Appeals to HHSC Texas Medicaid Fee-for-Service and PCCM" in Section 7, "Appeals" (Vol. 1, General Information) for information about submission of an appeal to HHSC.

A complaint is defined as any dissatisfaction expressed in writing by the provider, or on behalf of that provider, concerning Texas Medicaid. The term complaint does not include the following:

•A misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the provider's satisfaction.

•A provider's oral or written dissatisfaction with an adverse determination.

Under the complaint process, HHSC Claims Administrator Contract Management works with TMHP and providers to verify the validity of the complaint, determine if the established due process was followed in resolving appeals and grievances, and addresses other program and contract issues, as applicable.

Complaints must be written and received by HHSC Claims Administrator Contract Management within 60 calendar days from TMHP's written notification of the final appeal decision.

When filing a complaint, providers must submit a letter explaining the specific reasons they believe the final appeal decision by TMHP is incorrect and must supply copies of the following documentation:

•All correspondence and documentation from the provider to TMHP, including copies of:

•Supporting documentation submitted during the appeal process.

•All correspondence from TMHP to the provider, including TMHP's final decision letter.

•All R&S Reports of the claims/services in question, if applicable.

•Provider's original claim/billing record, electronic or manual, if applicable.

•Provider's internal notes and logs when pertinent.

•Memos from the state or TMHP indicating any problems, policy changes, or claims' processing discrepancies that may be relevant to the complaint.

•Other documents, such as certified mail receipts, original date-stamped envelopes, in-service notes, minutes from meetings, if relevant to the complaint. Receipts can be helpful when the issue is late filing.

Complaint requests may be mailed to the following address:

Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code 91X
PO Box 204077
Austin, TX 78720-4077

Refer to: Subsection 8.1.11, "Medicaid Managed Care Complaints and Fair Hearings" in this section.

Subsection 7.3.5.3, "Complaints to HHSC-Texas Medicaid Fee-for-Service and PCCM" in Section 7, "Appeals" (Vol. 1, General Information).