HEALTHfirst Medicaid STAR Member Complaints & Appeals

HEALTHfirst Medicaid STAR Member Complaints & Appeals

If you believe you have been discriminated against, your rights have been violated, or the wrong decision was made, you have options.

If you have a problem with your medical care or services, you have a right to file a complaint. A complaint can be filed when you are unhappy with your care. Some examples are:

  • The care you get from your doctor
  • The time it takes to get an appointment or be seen by a doctor
  • The doctors you can choose for care

What is an appeal? A request for your managed care organization to review a denial or a grievance again.

You have the right to ask for an appeal if you are not happy or disagree with and Adverse Benefit Determination. An Adverse Benefit Determination means the denial or limited authorization of a requested service. It includes:

  • the denial in whole or part of payment for a service
  • the denial of a type or level of service
  • the reduction, suspension, or termination of a previously authorized service

Parkland HEALTHfirst’s Member Advocate can help you file a complaint. Call 1-888-672-2277 to have a Member Advocate write down your complaint, or you can also mail a written complaint to:

TTY English 800-735-2989

Parkland Community Health Plan
Attention: Member Advocate
P. O. Box 560347
Dallas, TX 75356

Be sure to include the following:

  • Member's first and last name
  • ID number. It is on the front of the Member ID Card
  • Member's address and telephone number
  • Explain the problem

Once you have gone through the Parkland HEALTHfirst complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989. If you would like to make your Complaint in writing, please send it to the following address:

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
PO Box 13247
Austin, Texas 78711-3247

If you have Internet, you can submit your complaint at: hhs.texas.gov/managed-care-help

What are the requirements and timeframes for filing a complaint?

The member or provider can file a complaint anytime. The complaint can be oral or in writing. If the complaint is oral, a complaint form will be sent out to the member for a signature.

An acknowledgement letter will be sent to the member within the first. 5 business days of receipt of the complaint. A resolution to a complaint will be no longer than 30 calendar days.

Do I have a right to meet with a complaint appeal panel?

Within five (5) business days of getting your request for an Appeal of a Complaint, the Member Advocate will send you a letter to let you know that your complaint appeal came to us.

The Complaint Appeal Panel will look over the information you sent us and discuss your case. It is not a court of law. You have the right to appear in front of the Complaint Appeal Panel at a specific place to talk about the written complaint appeal you sent to us. When we make the decision on your appeal, we will send you a response in writing within thirty (30) calendar days after we receive your appeal.

Need more help?

If you receive benefits through Medicaid’s STAR program, call your medical or dental plan first. Once you have gone through the Parkland HEALTHfirst complaint process, if you didn’t get the help you need there, you should do one of the following:

  1. Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).
  2. Online: https://hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman
  3. Mail: Texas Health and Human Services Commission Office of the Ombudsman, MC H-700, P.O. Box 13247 Austin, TX, 78711-3247
  4. Fax: 1-888-780-8099 (toll-free)

Parkland HEALTHfirst’s Member Advocate can help you file an appeal. Call 1-888-672-2277 to have a Member Advocate write down your appeal, or you can also mail a written appeal to:

TTY English 800-735-2989

Parkland Community Health Plan
Attention: Member Advocate
PO Box 560347
Dallas, TX 75356

How will I find out if services are denied?

If your service or claim is denied, you will get a letter from Parkland Community Health Plan telling you about this decision. It will tell you about your right to appeal. You can also read about these rights in your Member Handbook.

What are the timeframes for the appeal process?

Your request for an appeal of denied or limited services including medication covered by Parkland HEALTHfirst must be filed within sixty (60) calendar days from the date of the decision letter.

To ensure continuity of currently authorized services, you must file the appeal on or before the later of 10 days following Parkland HEALTHfirst mailing of the notice of the action or the intended start date of the proposed adverse benefit determination.

Your request for an appeal can be verbal or in writing. If the appeal is received verbally, the Member Advocate will write down the information and send it to you for review and confirmation. You will need to return the form to the Member Advocate.

A written request can be sent to:

Parkland Community Health Plan
Attention: Member Advocate
PO Box 560347
Dallas, TX 75356

The resolution of your appeal can be extended up to fourteen (14) calendar days of the appeal if you ask for more time, or if Parkland HEALTHfirst can show that we need more information. We can only do this if more time will help you. We will send you a letter telling you why we asked for more time.

In some cases you have the right to receive an expedited decision. If you are in the hospital or experiencing a medical emergency that is being limited or denied, you can call and ask for an expedited appeal.

Does my request have to be in writing?

Your request does not have to be in writing. You can ask for an expedited appeal by calling Member Advocate.

What are the timeframes for an expedited appeal?

The timeframe for resolution will be based on your medical emergency condition, procedure, or treatment. Parkland HEALTHfirst will let you know the final decision of the expedited appeal in writing within twenty-four (24) hours.

What happens if Parkland HEALTHfirst denies the request for an expedited appeal?

If you ask for an expedited appeal that does not involve an emergency, an ongoing hospitalization, or services that are already being provided, you will be told that the appeal cannot be rushed. We will continue to work on the appeal within the standard timeframe and respond to you within thirty (30) days from the time the appeal was received.

After you have gone through all of Parkland HEALTHfirst’s appeals process, a Fair Hearing can be requested within 120 days from the appeal decision letter. The Appeal denial notification includes a Fair Hearing Enclosure and Fair Hearing Request Form for the member to complete and send to the health plan.

In the instance the MCO does not make a decision on an appeal within the 30 calendar day timeframe, the member may request a state fair hearing within 120 days from the date that is 30 days after the appeal request date.

Procedures for requesting a fair hearing

If a member or as the parent or guardian of a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a signed authorization letter to the health plan telling them:

  • The representative’s name
  • The representative’s title
  • The representative’s agency
  • The representative’s address
  • The representative’s phone number

A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 120 calendar days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 120 calendar days, you may lose your right to a fair hearing.

To ask for a fair hearing, you or your representative should call 1-888-672-2277 or mail a letter to:

Parkland Community Health Plan
Attention: Member Services
P. O. Box 569005
Dallas, TX 75356-9005
Fax: 877-223-4580

If you do not request a fair hearing by this date, the service the health plan denied will be stopped.

You have the right to continue to receive services the health plan denied or reduced, at least until the final hearing decision if the member requests a state fair hearing within 10 calendar days from Parkland Community Health Plan’s mailing of the Notice of Adverse Benefit Determination.

The member may be required to pay the cost of services furnished while the appeal is pending if the final decision is adverse to the member. A decision on a state fair hearing will be made in 90 days.