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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 6 NorthSTAR Program : 6.4 Complaints and Appeals

6.4
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 and grievances, hearings, or dispute resolution is the responsibility of ValueOptions. Providers must exhaust the appeals and 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 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 or appeals with NorthSTAR Provider Relations at the following address:
Department of State Health Services
NorthSTAR Enrollee/Provider Relations
PO Box 149347
Mail Code 2012
Austin, TX 78714-9347
Quality of care concerns can be submitted to ValueOptions or NorthSTAR Provider Relations at the following address:
ValueOptions
Attn: Complaint and Grievance Coordinator
1199 South Beltline, Suite 100
Coppell, TX 75019
Refer to:
Subsection 7.1.4, “Paper Appeals” in Section 7, “Appeals” (Vol. 1, General Information) for more information on paper appeals.

Texas Medicaid & Healthcare Partnership
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