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Reminder of Complaint Process and Enrollment for CPW Providers Operating in an MCO

Last updated on 9/13/2023

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Case Management for Children and Pregnant Women Program (CPW) providers that offer services in a managed care organization (MCO) are reminded of the correct process to follow for complaints or disputes.

When providers have a complaint or dispute, they must first contact the MCO and follow their internal appeal process to attempt to resolve the issue. Providers may file a complaint with the Texas Health and Human Services Commission (HHSC) if they believe that they did not receive full due process from the MCO or if they are not satisfied with the MCO’s determination.

Medicaid managed care providers can submit complaints and inquiries directly to HHSC Managed Care Contracts and Oversight (MCCO) through the following channels:

Texas Health and Human Services Commission

HHSC Health Plan Management

PO Box 149030

Mail Code: 0209

Austin, TX 78714-9030

Note: The HHSC Office of the Ombudsman does not handle any complaints from providers regarding MCOs or fee-for-service activities.

For questions about prior authorization, billing, or claims for clients enrolled in fee-for-service, contact TMHP at 800-925-9126.