Medicaid and CHIP Complaints and Appeals

Fee-for-Service

Medicaid fee-for-service providers must exhaust the administrative and medical appeals provider resolution process with the HHS claims administrator contractor before filing an appeal or complaint with HHSC.

Written appeals and complaints may be sent to HHSC at:

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

Provider Appeals of Medical Necessity and Utilization Review Decision

Appeals of HHSC Office of the Inspector General (OIG) Utilization Review (UR) Decisions

Written appeals may be sent to HHSC Medical and UR Appeals at:

HHSC Medical and UR Appeals
Mail Code H-230
4601 W. Guadalupe St.
Austin, TX 78751

Questions may be e-mailed to Utilization Appeals.

For additional information on Medical and UR Appeals, refer to HHSC Medical and UR Appeals.

Appeals of Recovery Audit Contractor (RAC) decisions

Written appeals are submitted through Health Management Systems, Inc. (HMS), not directly to HHSC Medical and UR Appeals.

For submissions by mail, please use the following address:

HHSC Medical and UR Appeals
C/O HMS
5615 High Point Drive
Mail Stop #200-TX
Irving, TX 75038

or

Make submissions via HMS Provider Portal.

For more information on appeals for RAC decisions, providers can contact HMS.

Managed Care

Medicaid managed care providers should exhaust the complaints or grievance process with their managed care medical or dental plan before filing a complaint with HHSC. If after completing this process, the provider believes they did not receive full due process from the managed care medical or dental plan, they may file a STAR, STAR+PLUS, STAR Health, STAR Kids or managed care dental complaint or inquiry by one of the below methods:

• Using the Online Question or Complaint Form
• Emailing HPM Complaints

• Mailing the complaint of inquiry to:

  Texas Health and Human Services Commission
  Medicaid/CHIP
  Health Plan Management
  Mail Code H-320
  P.O. Box 85200
  4900 N. Lamar
  Austin, TX 78708-5200

Resources

• Learn how to submit a complaint (PDF) for issues such as claims, what you will need and what you can expect.
• Health Plan Management Complaint Process flow chart (PDF)
• Accessible version of the steps in the complaint process (PDF)

Providers can submit appeals directly to the medical or dental plan that administers the clients' managed care benefits. Claims that originally were submitted to TMHP for routing to the appropriate medical or dental plan can be appealed to TMHP using TexMedConnect or EDI. The appeals will be routed to the appropriate entity for processing.

For additional information, read Texas Administrative Code, 1 TAC 354.