Complaints & Appeals

CHIP Complaints & Appeals

If you’re unhappy with your medical care or services, you can file a complaint or an appeal. Complaints can also be filed if you have issues with the quality of care and/or services you or your child receive, rudeness of a provider or employee, or failure to respect you or your child’s rights. Appeals can be filed if your doctor asks for a service for you or your child that is covered but CHRISTUS Health Plan denies it or limits it. Failure of CHRISTUS Health Plan to provide services in a timely manner and for a resident of a rural area with only one MCO, the denial of a Medicaid member's request to obtain services outside of the network.

An appeal means you may ask that the decision is looked at again by another qualified medical professional. The appeal will be reviewed by someone who did not make the original decision and does not report to the person who made the original decision. All requests for an appeal must be made within 30 calendar days from the date of this letter. You can send any comments, documents or other data to help with your appeal. If you want to file an appeal, call us at toll free 1-844-282-0380, toll free TTY 1-800-735-2989. You can also send your appeal to:

CHRISTUS Health Plan
Attn: Member Advocate
P.O. Box 169009
Irving, Texas 75016
Fax:
1-866-416-2840
Email: AppealsandGrievances@chhealthplans.org

You can file an appeal if your doctor asks for a service for you or your child that is covered but CHRISTUS Health Plan denies it or limits it.

You, a person acting on your behalf, or your provider may ask for a fast (expedited) appeal if you, a person acting on your behalf, or your provider believe that you have a life-threatening condition. We will also expedite your appeal if you are currently in the hospital or we have denied your emergency care. You can ask by phone if you need a fast appeal. Call us at 1-844-282-0380 to file a fast appeal.

Fast (expedited) appeals will be completed based upon the urgency of your medical condition, procedure, or treatment, and will not exceed one working day from the date all information necessary to complete the appeal is received.

For standard appeals, we will send you an acknowledgement letter within 5 working days from receipt of the appeal. We will resolve the appeal and send a written decision to you or someone acting on his/her behalf and the provider of record within 30 calendar days of receipt of the appeal.

A specialty appeal is available after the denial of an initial appeal. The provider of record may request this type of appeal in writing within 10 working days from the denial and must show good cause for the specialty appeal. We will complete the specialty appeal and send our decision in writing within 15 working days of receipt of the request for the specialty appeal.

If your doctor want to file a specialty appeal, call us at toll free 1-844-282-0380, toll free TTY 1-800-735-2989. You can also send your appeal to:

CHRISTUS Health Plan
Attn: Member Advocate
P.O. Box 169009
Irving, Texas 75016
Fax:
1-866-416-2840
Email: AppealsandGrievances@chhealthplans.org

If you disagree with a decision, you can appear in front of an Appeal Panel to talk about it. The Appeal Panel will look over the information you submitted and discuss your case. It is not a court of law. When we make the decision on your complaint appeal, we will send you a response in writing within 30 days from when we received the complaint appeal.

Once you have gone through the CHRISTUS Health Plan complaint process, you can complain to the Texas Department of Insurance (TDI) by calling 1-800-252-3439 or writing to:

Texas Department of Insurance
Consumer Protection
PO Box 149091
Austin, Texas 78714-9091

If you can get on the Internet, you can send your complaint in an email to: ConsumerProtection@tdi.texas.gov

If CHRISTUS Health Plan refuses to pay for your medical care, you might be able to have an independent review organization (IRO) review the decision. IROs are certified by the Texas Department of Insurance, and CHRISTUS Health Plan must comply with their decisions.


Asking for a Review:

If your condition is life-threatening, you have the right to an immediate review by the IRO. We may not require exhaustion of internal appeals prior to the review by the IRO if we have failed to meet our internal appeal process timelines, or if you file an IRO request in an urgent care situation prior to the completion of our internal appeals process. We will send you an IRO request form with the appeal denial letter.

The IRO will perform an expedited review for life-threatening (urgent care) services and issue a decision within three days of the request that the determination be made.

There isn't a deadline for requesting an IRO review, but it’s best to ask for a review as soon as possible. CHRISTUS Health Plan will pay for the cost of the IRO review.

CHRISTUS Health Plan will notify TDI of the request for a review. TDI will then assign your case to an IRO. If the IRO needs to see your medical records, you or your legal guardian will have to sign a consent form. You may give the IRO the records yourself or have CHRISTUS Health Plan do it. CHRISTUS Health Plan will send any medical records or information requested by the IRO within three days of the request. The IRO must keep your medical records and personal information confidential.

Don’t send your medical records to TDI.

The IRO has 20 days from the date TDI assigned your case to decide whether your plan must pay for the denied treatment. In cases involving life-threatening conditions, the IRO has three days to decide.

You can’t ask for an IRO review if your policy doesn't cover the denied service.


If your condition is life-threatening, you have the right to an immediate review by the IRO. We may not require exhaustion of internal appeals prior to the review by the IRO if we have failed to meet our internal appeal process timelines, or if you file an IRO request in an urgent care situation prior to the completion of our internal appeals process. We will send you an IRO request form with the appeal denial letter.

The IRO will perform an expedited review for life-threatening (urgent care) services and issue a decision within three days of the request that the determination be made.

There isn't a deadline for requesting an IRO review, but it’s best to ask for a review as soon as possible. CHRISTUS Health Plan will pay for the cost of the IRO review.

CHRISTUS Health Plan will notify TDI of the request for a review. TDI will then assign your case to an IRO. If the IRO needs to see your medical records, you or your legal guardian will have to sign a consent form. You may give the IRO the records yourself or have CHRISTUS Health Plan do it. CHRISTUS Health Plan will send any medical records or information requested by the IRO within three days of the request. The IRO must keep your medical records and personal information confidential.

Don’t send your medical records to TDI.

The IRO has 20 days from the date TDI assigned your case to decide whether your plan must pay for the denied treatment. In cases involving life-threatening conditions, the IRO has three days to decide.

You can’t ask for an IRO review if your policy doesn't cover the denied service.

If you are not happy with the care or services provided to you or your child by CHRISTUS Health Plan doctors, you can file a complaint.

Examples of other complaints can be the quality of care of services provided to you or your child, rudeness of a provider or employee of CHRISTUS Health Plan, or failure to respect your rights.

We want to help. If you have a complaint, please call us toll-free at 1-844-282-0380 to tell us about your problem. A CHRISTUS Health Plan Member Advocate can help you file a complaint. Most of the time, we can help you right away or at the most within a few days. You can also send a written complaint to the Member Advocate at:

CHRISTUS Health Plan
ATTN: Member Advocate
PO Box 169009
Irving, TX 75016
Fax:
1-866-416-2840
Email: AppealsandGrievances@chhealthplans.org

If you have a complaint, call us at 1-844-282-0380, and a member advocate can help you file it right away.

When we get a normal complaint from you, we will send you a letter within five (5) business days to let you know that your complaint came to us. We will send you another letter within thirty (30) days from the date we received your complaint that will give you the results of your complaint.

When we get the complaint from you, we will send you a letter within five business days to let you know that we received it. After your complaint is received, we will send you another letter within 30 days with the results.


If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance (TDI) by calling 1-800-252-3439 or writing to:

Texas Department of Insurance
Consumer Protection
PO Box 149091
Austin, Texas 78714-9091

If you can get on the Internet, you can send your complaint in an email to: ConsumerProtection@tdi.texas.gov


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Last updated: 2/23/17