Complaints and Appeals

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An appeal is the process you or someone acting on your behalf can request when you do not agree with the Health Plan's action and you want a review. This may be a denial or limited authorization of a requested service. You can find the appeals process on page 63 within the STAR Kids Member Handbook.

You may ask Cook Children's Health Plan for another review of this decision. This is called an "appeal." You can call Member Services and ask for an appeal.

If services are denied, we will send your provider a letter telling them why the service was denied. A copy of the letter will also be sent to you.

You may also call us at 1-844-843-0004 to ask for status of your appeal.

We will send you a letter within five working days to let you know:

That we received your request for appeal.
If we need any more information in order to process the appeal.
If you called us to request an appeal, you will receive a letter that tells you send a signed request in writing back to Cook Children's Health Plan.
We will complete the appeal no later than 30 calendar days from the date you asked for the appeal.

You may also call us at 1-844-843-0004 to ask for status of your appeal.

You may request an appeal whenever you do not agree with our decision to deny services or care for you.

We can accept your request orally or in writing. Mail written requests to:

Cook Children’s Health Plan
Attn: Appeals P.O. Box 2488
Fort Worth, TX 76113-2488
Call us at 1-844-843-0004

Yes, Member Services can help you file an appeal. They will send you an appeal request form (or download now) and ask that you send it back before your appeal request is taken. Call Member services at 1-844-843-0004.

An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

We can accept your request orally or in writing. Mail written requests to:

Cook Children's Health Plan
Attn: Appeals
PO Box 2488
Fort Worth, TX 76113-2488

If we deny an expedited appeal, it will be resolved within 30 days. You will get a letter telling you why and what other choices you may have.

We have one working day from the time we get the information and appeal request.

Member Services will help you. Call Member services at 1-844-843-0004.

If you, as 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 letter to the health plan telling them the name of the person you want to represent you. 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 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 120 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at:

Cook Children's Health Plan
Attn: Member Services
P. O. Box 2488
Fort Worth, TX 76113-2488

You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made if you ask for a fair hearing by the later of: (1) 10 business days following Cook Children’s Health Plan’s mailing of the notice of the action adverse benefit determination.

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 fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.

You may also call us at 1-844-843-0004 to ask for status. You can also find this information on page 65 within the STAR Kids Member Handbook.

Filing a Complaint

We want to help. If you have a complaint, please call us toll-free at 1-844-843-0004 to tell us about your problem. A Cook Children's Health Plan Member Services advocate can help you file a complaint. Most of the time we can help you right away or within a few days. You can also find the process of filing a complaint on page 62 within the STAR Kids Member Handbook.

For written complaints, please send your letter to Cook Children's Health Plan. Your letter must state your name, your Member ID number, your phone number and address and the reason for your complaint. Please send your letter to:

Cook Children's Health Plan
Attention: Complaints and Appeals
P.O. Box 2488
Fort Worth, TX 76113-2488

We can accept your request orally if you call us at 1-844-843-0004

There is no time limit on filing a complaint with Cook Children's Health Plan. We will send you a response letter telling you what we did about your complaint.

Most of the time we can help you right away or within a few days. You will get a response letter within 30 days from when your complaint was received by Cook Children's Health Plan.

Yes. Member Services can help you file a complaint. Call us at 1-844-843-0004.

Yes. You have the right to appear in person before the CAP or send a written appeal to the CAP.

If you are not satisfied with the answer to your complaint, you can notify the Texas Department of Insurance by calling 800-252-3439. If you would like to make your request in writing, send it to:

Texas Department of Insurance
Attention: Consumer Protection
P.O. Box 149091
Austin, TX 78714-9091

To submit your complaint online, visit www.tdi.texas.gov/consumer/get-help-with-an-insurance-complaint.html.

For questions about your complaint or appeal or to get the status of your complaint or appeal, please call Member Services at 1-844-843-0004.

Complaints and Appeals

What is an appeal?

What can I do if my doctor asks for a service or medicine for me that's covered, but Cook Children's Health Plan denies or limits it?

How will I find out if services are denied?

What are the timeframes for the appeal process?

When do I have the right to request an appeal?

Does my request have to be in writing?

Can someone from Cook Children's Health Plan help me file an appeal?

What is an expedited appeal?

Does my request for an expedited appeal have to be in writing?

What happens if Cook Children's Health Plan denies the request for an expedited appeal?

What are the timeframes for an expedited appeal?

Who can help me in filing an expedited appeal?

Can I ask for a State Fair Hearing?

Filing a Complaint

What should I do if I have a complaint? Who do I call?

Where can I mail a complaint?

Does my request for filing a complaint have to be in writing?

What are the requirements and timeframes for filing a complaint?

How long will it take to process my complaint?

Can someone from Cook Children's Health Plan help me file a complaint?

Do I have the right to meet with a Complaint Appeal Panel (CAP)?

If I am not satisfied with the outcome, who else can I contact?