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6.3.6 Complaints to HHSC-HMO Services
Medicaid Managed Care providers (HMOs) may file complaints to HHSC Health Plan Operations if they find they did not receive full due process from the HMOs. HHSC is only responsible for the management of complaints from managed care providers. Appeals/grievances, hearings, or dispute resolutions are the responsibility of the health plans. Providers must exhaust their appeals/grievance process with their health plan before filing a complaint with HHSC.
A complaint is defined as any dissatisfaction expressed in writing by the provider, or on behalf of that provider, concerning any aspect of 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.
Under the complaint process, HHSC works with the health plans 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/contract issues, as applicable.
Complaints must be in writing and received by HHSC within 60 calendar days from the health plan's written notification of the final action.
When filing a complaint, providers must submit a letter explaining the specific reasons they believe the final appeal decision by the health plan is incorrect and copies of the following documentation:
• All correspondence and documentation from the provider to the health plan, including copies of supporting documentation submitted during the appeals process.
•All correspondence from the health plan to the provider. Correspondence includes the initial determination letter; all appeal determination letters, and the 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 the health plan 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 for HMO's may be mailed to the following address:
Texas Health and Human Services Commission
Re: Provider Complaint
Health Plan Operations, H-320
PO Box 85200
Austin, TX 78708
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