Complaints & Appeals

Medicaid Appeals & Complaints

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 of 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
PO Box 169009
Irving, Texas 75016
Fax:
1-866-416-2840
Email: AppealsandGrievances@chhealthplans.org

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 of 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.

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.

If you are appealing because you have an ongoing emergency or denial of continued Hospitalization, we will process your appeal and give you an answer within one (1) working day.

If you are already getting services, you, person acting on your behalf or your provider may ask that they be continued until you find out the results of your appeal. You may have to pay for the services if the decision is upheld.

For all other fast appeal, we will process your appeal and give you an answer no later than three (3) working days from the day we get your fast appeal request.

For standard appeal, 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 you 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
PO Box 169009
Irving, Texas 75016
Fax:
1-866-416-2840
Email: AppealsandGrievances@chhealthplans.org


If you disagree with CHRISTUS Health Plan decision, you have the right to ask for a Medicaid fair hearing from the Health and Human Services Commission (HHSC). You may represent yourself at the fair hearing, or name someone else to be your representative. This could be a doctor, relative, friend, lawyer, or any other person. You may name someone to represent you by writing a letter to CHRISTUS Health Plan telling them the name of the person that you want to represent you. If you want to challenge a decision made by CHRISTUS Health Plan, you or your representative must ask for the Medicaid fair hearing within ninety (90) days of the date that you received a letter from the Health Plan informing you that your services have been changed. If you do not request a Fair Hearing within 90 days, you may lose your right to a Fair Hearing. To request a Fair Hearing you or your representative need to contact CHRISTUS Health Plan by telephone toll free at 1-844-282-0380 or toll free TTY 1-800-735-2989 in writing to:

CHRISTUS Health Plan
ATTN: Member Advocate
PO Box 169009
Irving, Texas 75016
Fax:
Email: AppealsandGrievances@chhealthplans.org

If you believe that waiting for a fair hearing will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you or your representative may ask for an expedited fair hearing by writing or calling CHRISTUS Health Plan. To qualify for an expedited fair hearing through HHSC, you must first complete CHRISTUS Health Plan’s internal appeals process.

You have a right to continue any service you are now receiving until the final hearing decision is made if you ask for a fair hearing by: (1) 10 calendar days following the mailing of this letter, or (2) the day CHRISTUS Health Plan’s letter says your service will be reduced or end. If you do not request a fair hearing by this date, the service CHRISTUS Health Plan denied will be stopped.

If you lose your fair hearing appeal, CHRISTUS Health Plan may be able to recover the costs of providing the service or benefit to you while the appeal was pending.

If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most hearings are held by telephone. You can also contact the HHSC hearings officer if you would like the hearing to be held in-person. During the hearing, you or your representative can tell why you need the service or why you disagree with CHRISTUS Health Plan’s action. You have the right to examine, at a reasonable time before the date of the fair hearing, the contents of your case file and any documents to be used by CHRISTUS Health Plan at the hearing. Before the hearing, CHRISTUS Health Plan will send you all of the documents to be used at the hearing. HHSC will give you a final decision within 90 days from the date you asked for the hearing.

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 the 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.


Members can file with HHSC if they don't get the help they need through CHRISTUS Health Plan by calling:

1-866-566-8989 or mail to:
Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
PO Box 13247
Fax 1-888-780-8099


If you can get on the Internet, you can send your complaint in an email to: HPM_Complaints@hhsc.state.tx.us.






MM163
Last updated: 2/23/17