TMPPM 2008 > Provider Information > Appeals > Appeals to HHSC Fee-for-Service and PCCM

6.3.5 Complaints to HHSC-Fee-for-Service and PCCM

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

Refer to: "Appeals to HHSC Fee-for-Service and PCCM" 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 the Texas Medicaid Program. The term complaint does not include 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 and does not include a provider's oral or written dissatisfaction with an adverse determination.

Under the complaint process, the 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 in writing and received by the 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 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 receipts (i.e. certified mail), original date-stamped envelopes, in-service notes, minutes from meetings, etc., 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