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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:
  • 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

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.

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