An official State of Texas website.
Revision 11-4; Effective December 1, 2011
The managed care organization (MCO) must develop, implement and maintain a member complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including Code of Federal Regulations 42, §431.200, 42 CFR Part 438, Subpart F, Grievance System, and the provisions of Texas Administrative Code 1, Chapter 357, relating to Medicaid managed care organizations.
The MCO's complaint and appeal systems must include:
- a complaint process;
- an appeal process; and
- access to the Health and Human Services Commission fair hearing process.
4110 MCO Complaint Procedures
Revision 14-1; Effective March 3, 2014
The Health and Human Services Commission's (HHSC) Uniform Managed Care Contract Terms and Conditions, Attachment A, defines a complaint as:
"an expression of dissatisfaction expressed by a Complainant, orally or in writing to the managed care organization (MCO), about any matter related to the MCO other than an Action. As provided by 43 CFR §438.400, possible subjects for Complaints include, but are not limited to, the quality of care of services provided, and aspects of interpersonal relationships, such as rudeness of a provider or employee, or failure to respect the Medicaid Member's rights."
The complaint procedure does not apply to situations described in "Appeal Procedures."
When a managed care organization (MCO) member wants to file a complaint, he or she must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO must provide a designated member advocate to assist the member in using the complaint system. The advocate must assist members in writing or filing a complaint, and monitor the complaint throughout the process until the issue is resolved.
If the member is not satisfied with the outcome of the MCO complaint process, he or she sends a written request to HHSC to investigate the complaint. The request is sent to:
Texas Health and Human Services Commission Managed Care Operations – STAR+PLUS Mail Code H-320 P. O. Box 13247 Austin, TX 78711
If a STAR+PLUS member contacts any HHSC employee with a complaint regarding an agency licensed by HHSC, the member is referred to 800-458-9858 to file a regulatory complaint.
Members may also call the Medicaid hotline at 800-252-8263 to file a complaint not related to licensure issues.
4120 MCO Appeal Procedures
Revision 14-1; Effective March 3, 2014
The Health and Human Services Commission's Uniform Managed Care Contract Terms and Conditions, Attachment A, defines an appeal as the formal process by which a member or his or her representative requests a review of the managed care organization’s (MCO’s) action. An action is:
- the denial or limited authorization of a requested Medicaid service, including the type or level of service;
- the reduction, suspension or termination of a previously authorized service not caused by loss of eligibility;
- denial in whole or in part of payment for service;
- failure to provide services in a timely manner;
- failure of an MCO to act within the time frames set forth in the contract and 42 Code of Federal Regulations (CFR) §438.408(b); or
- for a resident of a rural area with only one MCO, the denial of a Medicaid member's request to obtain services outside of the network.
The member may file an appeal by contacting the MCO following the procedures specified in the MCO's member handbook. The MCO is contractually required to regard any oral or written expression of dissatisfaction or disagreement as a request to file an appeal. The MCO must provide a designated member advocate to assist the member in filing an appeal. The advocate must also assist members by monitoring the appeal throughout the process until the issue is resolved.
During the appeal process, the MCO must provide the member a reasonable opportunity to present evidence and any allegations of fact or law in person, as well as in writing. The MCO must inform the member of the time available for providing this information and that in the case of an expedited resolution, limited time will be available.
The MCO must provide the member and his or her representative the opportunity, before and during the appeal process, to examine the member's case file, including medical records and any other documents considered during the appeal process.
As required by 42 CFR §438.420, the MCO must continue the individual's benefits pending the outcome of the appeal if all the following criteria are met:
- appeal is filed by the effective date of action;
- appeal involves termination, suspension or reduction of a previously authorized course of treatment;
- services were ordered by an authorized provider; and
- original period covered by the authorization has not expired.
4121 Expedited MCO Appeals
Revision 11-4; Effective December 1, 2011
In accordance with 42 Code of Federal Regulations §438.410, and Uniform Managed Care Contract (UMCC) Attachment B-1, Section 8.2.7.3, the managed care organization (MCO) must establish and maintain an expedited review process for service-related appeals when the MCO determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking the time for a standard resolution could seriously jeopardize the member’s life or health. The MCO must follow all appeal requirements for standard member appeals as set forth in UMCC Attachment B-1, Section 8.2.7.2, except where differences are specifically noted. The MCO must accept oral or written requests for expedited appeals.
After the MCO receives a request for an expedited appeal, the MCO must notify the member of the outcome of the expedited appeal request within three business days. However, the MCO must complete investigation and resolution of an appeal relating to an ongoing emergency or denial of continued hospitalization:
- in accordance with the medical or dental immediacy of the case; and
- not later than one business day after receiving the member's request for expedited appeal.
Members must exhaust the MCO’s expedited appeal process before making a request for an expedited state fair hearing.
Except for an appeal relating to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited appeal may be extended up to 14 calendar days if the member requests an extension or the MCO shows (to the satisfaction of the Health and Human Services Commission (HHSC), upon HHSC’s request) that there is a need for additional information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.
If the decision is adverse to the member, the MCO must follow the procedures relating to the notice in UMCC Attachment B-1, Section 8.2.7.5. The MCO is responsible for notifying the member of his/her right to access an expedited fair hearing from HHSC. The MCO is responsible for providing documentation to the state and the member, indicating how the decision was made, prior to HHSC’s expedited fair hearing.
The MCO is prohibited from discriminating or taking punitive action against a member or his/her representative for requesting an expedited appeal. The MCO must ensure that punitive action is neither taken against a provider who requests an expedited resolution, nor supports a member’s request.
If the MCO denies a request for expedited resolution of an appeal, the MCO must:
- transfer the appeal to the time frame for standard resolution; and
- make a reasonable effort to give the member prompt oral notice of the denial, and follow up within two calendar days with a written notice.