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Cook Children's Health Plan

Complaints and Appeals

Provider Complaint Process

Contracted providers are an essential part of delivering quality care to our Members.

A complaint is defined as dissatisfaction expressed by a complainant with any aspect of the health plan's operation. The complaint process does not include appeals related to Medical Necessity or disenrollment decisions. A complaint does not include misinformation that is resolved promptly by supplying the appropriate information or clearing up a misunderstanding to the satisfaction of the complainant.

Providers that wish to file a complaint about Cook Children's Health Plan or one of our Members can do so by submitting their complaint in writing. Upon receipt of the complaint the health plan will send an acknowledgement letter to the provider within five (5) business days. Cook Children's Health Plan will fully and completely respond to all provider complaints within thirty (30) calendar days of receiving the complaint. Telephone communication related to the complaint will be documented in a complaint log. Email and fax documentation related to the complaint will be retained by the health plan for a period of seven (7) years. Providers may submit a written complaint as follows:

If the Provider is not happy with the resolution of the complaint, they have the right to file a complaint with the Health and Human Services Commission (HHSC). When filing a complaint with HHSC, Providers must send a letter within sixty (60) calendar days of receiving Cook Children's Health Plan's resolution letter. The letter must explain the specific reasons you believe Cook Children's Health Plan's complaint resolution is incorrect. The complaint should include:

  • All correspondence and documentation sent to Cook Children's Health Plan, including copies of supporting documentation submitted during the complaint process
  • All correspondence and documentation you received from Cook Children's Health Plan
  • All remittance and status reports of the claims/services in question, if applicable
  • Provider's original claim/billing record, electronic or manual, if applicable
  • Provider internal notes and logs when pertinent
  • Memos from the state or health plan indicating any problems, policy changes, or claims processing discrepancies that may be relevant to the complaint
  • Other documents, such as certified mail receipts, original date-stamped envelopes, in service notes or minutes from meetings if relevant to the complaint. Receipts can be helpful when the issue is late filing
  • When filing a complaint with Health and Human Services Commission, providers must submit a letter to the following address:

    Texas Health and Human Services Commission
    Re: Provider Complaint
    Health Plan Operations, H-320
    PO Box 85200
    Austin, TX 78708

  • Submitting a written complaint by email to: HPM_Complaints@hhsc.state.tx.us
  • How to submit a complaint as a Medicaid Provider

Provider appeals must be submitted in writing and received by the health plan within one hundred twenty (120) calendar days of the printed disposition date on the explanation of payment. Supporting documentation may include but is not limited to:

  • Letter from the provider stating why they feel the claim payment is incorrect (required)
  • Copy of the original claim
  • Copy of the health plan explanation of payment
  • Explanation of payment from another insurance company
  • Prior authorization number and/or form or fax documenting the prior authorization determination
  • Eligibility verification documentation
  • Electronic acceptance reports confirming the claim was received by the health plan
  • Overnight or certified mail receipt as proof of filing received date by the health plan

Providers may submit appeals online through our secure provider portal and selecting Provider Appeal. Supporting documentation can be uploaded using the attachment feature. Written appeals should be mailed or faxed to:

Cook Children's Health Plan
Attention: Appeals
P.O. Box 2488
Fort Worth, TX 76113-2488
Fax: 682-885-8404
Phone: 888-243-3312
CCHPClaimAppeals@cookchildrens.org

Changes or errors in CPT codes are not considered payment appeals. Corrected claims should be resubmitted to the health plan with a notation of corrected claim.

Cook Children's Health Plan Appeal Process

Cook Children's Health Plan maintains an internal appeal process for the resolution of medical necessity appeal requests. Cook Children's Health Plan will send a letter that informs the Member, the servicing Provider, and the ordering Provider of the Member's appeal rights, including but not limited to:

  • The Process to request an internal appeal
  • Expected timeframe for our response to an appeal request
  • Process to obtain a free copy of the criteria used to make the decision
  • How to request an Expedited (Emergency) Appeal
  • Rights to External Medical Review (EMR)/Independent Review Organization (IRO)
  • State Fair Hearing Process

The Member or the Member's representative may appeal an adverse benefit determination (medical necessity denial) orally or in writing. The Member may consent for a healthcare provider to act on his or her behalf as the authorized representative during the internal appeal process. Cook Children's Health PLan will send an appeal acknowledgement letter to the Member within five (5) calendar days of the appeal request.

When Cook Children's Health Plan denies or limits a covered benefit, the Member/Provider must file an Appeal request within sixty (60) days from receipt of the Notice of Adverse Benefit Determination (or ten (10) business days to ensure continuation of currently authorized services). The Member or Member's Representative must request to continue services during the appeal process.

The Standard Appeal Process will be completed within thirty (30) calendar days after receipt of the request for appeal, unless an Expedited Appeal is requested, which will be completed within seventy-two (72 hours) from the time we get the appeal request and supporting information. An expedited appeal is when Cook Children's Health Plan has to make a decision quickly based on the condition of the Member's Health, and taking time for a standard appeal could jeopardize their health or life. If the request for Expedited appeal is denied, the appeal will be resolved within thirty (30) days.

Appeals are reviewed by individuals who were not involved in the original review or decision to deny and are health care professionals with appropriate clinical expertise. Cook Children's Health Plan provides a written notice of the appeal determination to the Member and Provider. If the appeal resolution reverses the denial, Cook Children's Health Plan will promptly authorize coverage. If the appeal decision upholds the original decision to deny a service, Members will receive information regarding their right to request an External Medical Review and/or State Fair Hearing.

To learn more about appeal rights or request assistance with initiating an appeal, the Member or the Member's representative may call CCHP at 682-885-2247 or toll-free 1-800-964-2247, send email communication to CCHPDenialandappeal@cookchildrens.org or send a letter to:

Cook Children's Health Plan
Attn: Denial and Appeal Coordinator
P.O. Box 2488
Fort Worth, TX 76101-2488

State Fair Hearing/External Medical Review Process

After exhausting Cook Children's Health Plan internal appeal process, the Member has the right to request External Medical Review and/or State Fair Hearing. The request for State Fair Hearing/External Medical Review must be requested within one hundred-twenty (120) calendar days of the date that the health plan mailed the appeal decision letter or the right to request State Fair Hearing/External Medical Review is waived.

The External Medical Review (EMR) is an optional, extra step a Member may request to further review Cook Children's Health Plan's adverse benefit determination. The EMR will take place between Cook Children's Health Plan's internal appeal and the State Fair Hearing. The Member or Member's authorized representative may request one option orally or in writing:

  • State Fair Hearing only
  • External Medical Review and State Fair Hearing
  • Emergency State Fair Hearing only*
  • Emergency State Fair Hearing and Emergency External Medical Review*

*Emergency Stair Fair Hearings and Emergency External Medical Review should only be requested if the Member or Member's representative believe the Member's health will be seriously harmed by waiting for the State Fair Hearing or External Medical Review decisions.

Upon Member request, following the internal appeal, the EMR process will be conducted by a separate entity, Independent Review Organization (IRO). The IRO is contracted by HHSC to complete an independent review of the healthcare services that were denied by the health plan. The IRO will decide whether Cook Children's Health Plan's original adverse benefit determination must be reversed or affirmed.

Cook Children's Health Plan will send all documentation utilized to make it service reduction or denial decision, including information submitted by the Member, the Member's authorized representative, or the Provider during the internal appeal process to the HHSC EMR Intake Team for processing per the following timelines;

  • Expedited (Emergency) EMR requests will be sent within one (1) day of receiving the EMR request, unless received after 3:00 PM CST on Friday or on a day CCHP is closed for business, the Expedited EMR request will be sent no later than noon the following business day.
  • Standard EMR requests will be sent by the health plan no later than three (3) days after receiving the EMR request from the Member or the Member's Legal Authorized Representative (LAR).

The HHSC EMR Intake Team is responsible for assigning EMR requests to IROs and will monitor the EMRs for timely completion and ensure communication to Member and CCHP of IRO determination.

  • IRO decision to Uphold - this means IRO agrees with the health plan's adverse determination to deny services.
  • IRO decision to Partially Overturn - this means the IRO did not agree with the health plan's adverse determination entirely and will approve in part.
  • IRO decision to Overturn - this means the IRO did not agree with the health plan's adverse determination and the denial has been reversed. The health plan will reinstate the services within seventy-two (72) hours of notification of the EMR decision to overturn.

Following the final EMR determination, the Member or authorized representative must decide to continue to State Fair Hearing as scheduled or formally withdraw the request for State Fair Hearing. The Member and Cook Children's Health Plan have a right to request for the IRO to attend the State Fair Hearing.

To learn more about the Member's External Medical Review/State Fair hearing process and/or request assistance, the Member or Member's Representative can contact Cook Children's Health Plan at 682-885-2247 or toll free at 1-800-964-2247, send an email to CCHPDenialandappeal@cookchildrens.org, go in person to a local HHSC office, or send a letter to:

Cook Children's Health Plan
Attn: Denial and Appeal Coordinator
P.O. Box 2488 Fort Worth, TX 76101-2488

If there are more questions about the health plan appeal process, call an HHSC Ombudsman at 1-866-566-8989 or complete the online form at www.hhs.texas.gov/managed-care-help.

Providers may appeal claim recoupment by submitting the following information to Health and Human Services Commission: A letter indicating that the appeal is related to a managed care disenrollment/recoupment and that the provider is requesting an Exception Request.

  • The Explanation of Benefits (EOB) showing the original payment. Note: This is also used when issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an authorization for the exact items that were approved by the plan.
  • The EOB showing the recoupment and/or the plan's "demand" letter for recoupment. If sending the demand letter, it must identify the client name, identification number, DOS and recoupment amount. The information should match the payment EOB.
  • Completed clean claim. All paper claims must include both the valid NPI and TPI number. Note: In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted with the authorization number and the provider will need to submit a corrected claim that contains the valid authorization number.

Mail appeal requests to:

Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
P.O. Box 204077
Austin, Texas 78720-4077