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A Guide on How to Submit Provider Complaints to Texas Health and Human Services

By J.R. Top posted Jun 22,2017 12:43 PM

  

Filing a Provider Complaint with Texas Health and Human Services

Providers can file complaints or inquiries with HHS Health Plan Management (HPM) for the following programs  STAR, STAR+PLUS, or managed care dental at: HPM_Complaints@hhsc.state.tx.us

STAR Health complaints or inquires should be sent to: STAR.Health@hhsc.state.tx.us


Complaint Types

When a contact is received by HPM complaints, it will be logged/assigned as one of the following action types:

  • Complaint: An expression of dissatisfaction expressed by a provider or member or other individual designated to act on behalf of the Member, verbally or in writing to HHSC, about any matter related to the MCO other than an Action.
  • Inquiry: A request for information directed to HHSC from a Medicaid stakeholder, including a Medicaid member, a Medicaid member representative (including an elected official or advocate), or a Medicaid provider.
  • Legislative: Can either be a complaint or inquiry, initiated by a Legislative office.

The Complaint Coordinator will use independent judgement to determine the action type, based on the initial contact; however the HP Tech assigned to working the case, will make the final determination.


Complaint Guidance

Since HHS uses the above criteria for complaints and inquiries, it is recommended that when filing a verbal or written complaint to HPM Complaints that your dissatisfaction is clear by writing in the complaint “I am expressing my dissatisfaction about (matters related to the complaint).” If you do not emphasize your dissatisfaction, your email will not be registered as a complaint.

You may also want to use the phrase, “Formal Complaint” in your email title, (e.g. “Formal Complaint–MCO Payment Delay”).


HPM Complaints FAQs (answered January 13, 2017)

Q: Is an HP Tech a Health Plan Tech or a contracted tech?

A: HHSC Health Plan Technician.

 

Q: When a contact is logged, does HPM track it by topic?

A: HPM Complaints are tracked by category, e.g. Member Fair Hearing/Appeals; Member Eligibility/Enrollment; Member Access to Care; Provider Enrollment, etc.

 

Q: What is the timeframe for responses to a complaint or inquiry?

A: For both complaints and inquiries, if the case is:

  • Legislative there is a 24 hour turnaround for the plan to respond;
  • Access to Care cases have 1 to 3 days for the plan to respond;
  • HHSC Expedited cases have 1 to 5 days for the plan to respond and routine cases (denial of claim is an example) have 10 business days for plans to respond.

Note: Please keep in mind that responding doesn't necessarily mean resolving, however the plan is required to provide a timeframe for final resolution.

Q: How are the responses given to the member/provider? (Writing, email, phone call, U.S. Mail?)

A: HPM utilizes all communication formats to respond to members and providers including telephone calls, emails, and written letters.

 

Q: Are complaints or inquiries that are received by the Ombudsman also tracked by HPM Complaints?

A: HPM does not track the Ombudsman's complaints; however, all complaints received by HPM and the Ombudsman are recorded in the HEART database system. There is a global function within the HEART database which allows HPM to view Ombudsman's complaints and vice‐versa. This allows both groups to view specific case documentation, increasing coordination.

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