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7.4.6 Complaints and Appeals
A complaint is defined as any dissatisfaction expressed in writing by the provider, or on behalf of that provider, concerning any aspect of the health plan. 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.
Appeals/grievances, hearings, or dispute resolution is the responsibility of ValueOptions. Providers must exhaust the appeals/grievance process with ValueOptions before filing a complaint with NorthSTAR Provider Relations. Under the complaint process, NorthSTAR Provider Relations works with ValueOptions 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. When filing a complaint, providers must submit a letter explaining the specific reasons they believe the final appeal decision by the NorthSTAR health plan is incorrect and copies of the following documentation as appropriate:
• All R&S reports of the claims/services in question, if applicable.
•Provider's claims/billing records (electronic or manual) related to the complaint.
•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.
All NorthSTAR providers must exhaust the ValueOptions complaint and appeals process first. After this process is exhausted and if the outcome is unsatisfactory, NorthSTAR providers may file complaints/appeals with NorthSTAR Provider Relations at the following address:
NorthSTAR Provider Relations
DSHS
909 W. 45th Street
PO Box 12668
Austin, TX 78711-2668
Quality Improvement Monitoring
Direct quality of care concerns to ValueOptions or NorthSTAR Provider Relations at the following address:
NorthSTAR Provider Relations
DSHS
909 W. 45th Street
PO Box 12668
Austin, TX 78711-2668
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