Complaints & Appeals

What is a complaint? If you are unhappy with the care or services provided to you or your child by a participating provider, you can file a complaint.  If you are unhappy with the benefits for you or your child including exclusions, limitations, non-­covered benefits, or the appropriateness of a health care service for you or your child, you can file a complaint.

What is an appeal? An Appeal means the formal process by which a member or his or her representative request a review of the MCO’s actions.

If you have questions about the process or status of your complaint, appeal, or state fair hearing, or to make an oral request for one, please call us at:

Medicaid STAR 1-800-248-7767 (Bexar), 1-800-306-8612 (Tarrant) Medicaid STAR Kids 1-844-STRKIDS (1-844-787-5437) CHIP or CHIP Perinate 1-866-818-0959 (Bexar), 1-800-245-5380 (Tarrant) 1-800-735-2989 (for the hearing impaired)  Fax number 1-877-223-4580

 

 

Complaints Process

We want to help. If you have a complaint, please call us toll‑free at 1‑844‑STRKIDS (1‑844‑787‑5437 (STAR Kids,) 1-800-306-8612 (STAR for Tarrant) or 1‑800‑248‑7767 (STAR for Bexar) to tell us about your problem. An Aetna Better Health Member Services Advocate can help you file a complaint. Just call 1‑844‑STRKIDS (1‑844‑787‑5437 (STAR Kids), 1-800-306-8612 (STAR for Tarrant) or 1‑800‑248‑7767 (STAR for Bexar)1‑800‑306‑8612 (Tarrant), 1‑800‑248‑7767 (Bexar). Most of the time, we can help you right away or at the most within a few days.

If you receive benefits through Medicaid’s STAR or STAR Kids program, call your medical or dental plan first. Once you have gone through the Aetna Better Health complaint process, if you didn’t get the help you need there, you should do one of the following:

  1. Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).
  2.  Online: https://hhs.texas.gov/about-hhs/your-rights/hhs-office-ombudsman
  3. Mail: Texas Health and Human Services Commission Office of the Ombudsman, MC H-700

    P.O. Box 13247 Austin, TX 78711-3247

  4.  Fax: 1-888-780-8099 (toll-free) 

If you can get on the Internet, you can send your complaint in an email to HPM_Complaints@hhsc. state.tx.us.

 

Our Member Advocate can help you file a complaint. The Member Advocate will write down your concern. You can also send a written complaint to the Member Advocate at:

Aetna Better Health Attention: Member Advocate P.O. Box 569150 Dallas, TX 75356‑9150 1‑800‑306‑8612 (Tarrant)

1‑800‑248‑7767 (Bexar)

1‑844‑STRKIDS (1‑844‑787‑5437) (STAR Kids)

When we get the complaint from you, we will send you a letter within five (5) business days to let you know that your complaint came to us. We will send you another letter within thirty (30) calendar days from the date we got your complaint that will give you the results.

The member or provider can file a complaint/grievance anytime.  The complaint/grievance can be oral or in writing.  If the complaint/grievance is oral, a complaint/grievance form will be sent out to the member for a signature.  An acknowledgement Letter will be sent to the member within the first 5 business days of receipt of the complaint/grievance.  A resolution to a complaint will be no longer than 30 calendar days.   

If you have a complaint, please call us toll‑free at: at 1‑844‑STRKIDS (1‑844‑787‑5437) (STAR Kids), at 1-800-306-8612 (Tarrant) or 1‑800‑248‑7767 (Bexar)

 

If you are not happy, you can call us at the toll‑free number on your ID card and ask for an appeal. You can ask for an appeal of a complaint resolution by writing to:

Aetna Better Health Attention: Member Advocate P.O. Box 569150 Dallas, TX 75356‑9150 1‑844‑STRKIDS (1‑844‑787‑5437) (STAR Kids), 1‑800‑306‑8612 (Tarrant) or 1‑800‑248‑7767 (Bexar).

 

Within five (5) business days of getting your request for an Appeal of a Complaint, the Member Advocate will send you a letter to let you know that your complaint appeal came to us. The Complaint Appeal Panel will look over the information you sent us and discuss your case. It is not a court of law.  You have the right to appear in front of the Complaint Appeal Panel at a specific place to talk about the written complaint appeal you sent to us. When we make the decision on your appeal, we will send you a response in writing within thirty (30) calendar days after we receive your appeal. 

Appeal process

 

Aetna Better Health will send you a letter about an action on a covered service that your doctor requests. An action means the denial or limited authorization of a requested service. It includes:

  • the denial in whole or part of payment for a service
  • the denial of a type or level of service
  • the reduction, suspension, or termination of a previously authorized service 

You have the right to ask for an appeal if you are not happy or disagree with the action. An appeal is the process by which you or a person authorized to act on your behalf, including your doctor, requests a review of the action. You or your doctor can send any additional medical information which supports why you disagree with the decision. You can call us at the toll‑free number on your ID card and ask for an appeal. The Member Advocate will write down the information and send it to you for review. A written appeal can be sent to:

Aetna Better Health Attention:

Member Advocate P.O. Box 569150

Dallas, TX 75356‑9150

If services are denied, you and your doctor will get a letter that tells you the reason for denial. The letter will tell you how to file an appeal and how to ask for a State Fair Hearing.

Your request for an appeal of denied or limited services including medication covered by Aetna must be filed within sixty (60) calendar days from the date of the decision letter. To ensure continuity of currently authorized services, you must file the appeal on or before the later of 10 days following Aetna Better Health mailing of the notice of the action or the intended start date of the proposed action. Aetna will send you a letter within five working days to let you know we received your appeal request. You will get a letter with Aetna’s decision within 30 calendar days from when you asked for the appeal. In some cases you have the right to receive an expedited decision. The expedited appeal process is explained below. If you are in the hospital or are already receiving services that are being limited or denied, you can call and ask for an expedited appeal.

Your request for an appeal can be verbal or in writing. If the appeal is received verbally, the Member Advocate will write down the information and send it to you for review. You will need to return the form to the Member Advocate.

A written request can be sent to:

Aetna Better Health Attention: Member Advocate P.O. Box 569150 Dallas, TX 75356‑9150

The resolution of your appeal can be extended up to fourteen (14) calendar days of the appeal if you ask for more time, or if Aetna Better Health can show that we need more information. We can only do this if more time will help you. We will send you a letter telling you why we asked for more time.

Once you have gone through the Aetna Better Health appeal process, you can request a Fair Hearing through the Texas Health and Human Services Commission (HHSC) by calling 1‑866‑566‑8989 or writing to:

Texas Health and Human Services Commission Health Plan Operations H‑320 ATTN: Resolution Services P.O. Box 85200O Austin, TX 78708‑5200

If you can get on the internet, you can send your complaint in an email

State Fair Hearing

A Fair Hearing can be requested within 120 days from the appeal decision letter. The Appeal denial notification includes a Fair Hearing Request Form (English/Spanish) for the member to complete and send to the health plan.

In the instance the MCO does not make a decision on an appeal within the 30 calendar day timeframe, the member may request a state fair hearing within 120 days from the date that is 30 days after the appeal request date.

If a member or as the parent or guardian of 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 signed authorization letter to the health plan telling them:

  • The representative’s name
  • The representative’s title
  • The representative’s agency
  • The representative’s address
  • The representative’s phone number

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 calendar days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 120 calendar 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: Aetna Better Health Attention: Member Advocate P.O. Box 569150 Dallas, TX 75356-9150 or call 1‑844‑STRKIDS (1‑844‑787‑5437 (STAR Kids,) 1-800-306-8612 (STAR for Tarrant) or 1‑800‑248‑7767 (STAR for Bexar). If you do not request a fair hearing by this date, the service the health plan denied will be stopped.

You have the right to continue to receive services the health plan denied or reduced, at least until the final hearing decision if member requests a state fair hearing within: (1) 10 calendar days from Aetna Better Health’s mailing of the Notice of Action.  The member may be required to pay the cost of services furnished while the appeal is pending if the final decision is adverse to the member.  A decision on a state fair hearing will be made in 90 days.

STAR: 1-800-248-7767 (Bexar County)

STAR 1-800-306-8612 (Tarrant County)

STAR Kids: 1-844-787-5437

Aetna Better Health                              

Attn: Member Advocate                        

P O Box 569150                                        

Dallas, TX 75356-9150       

Phone: 1-800-248-7767 (Bexar County)

Phone: 1-800-306-8612 (Tarrant County)

Phone: 1-844-787-5437

STAR - 1-800-248-7767 (Bexar County)

STAR - 1-800-306-8612 (Tarrant County)

STAR Kids - 1-844-787-5437

CHIP/CHIP Perinate complaint process

We want to help. If you have a complaint, please call us toll‑free at 1‑800‑245‑5380 (Tarrant) or 1‑866‑818‑0959 (Bexar) to tell us about your problem. An Aetna Better Health Member Services Advocate can help you file a complaint. Just call 1‑800‑245‑5380 (Tarrant) or 1‑866‑818‑0959 (Bexar). Most of the time, we can help you right away or at the most within a few days.

The Member Advocate can help you file a complaint. The Member Advocate will write down your concern. You can also send a written complaint to the Member Advocate at:

Aetna Better Health
Attention: Member Advocate
PO Box 569150
Dallas, TX 75356‑9150
1‑800‑245‑5380 (Tarrant) or 1‑866‑818‑0959 (Bexar)

When we get the complaint from you, we will send you a letter within five (5) days to let you know that we got it. We will send you another letter within thirty (30) days from the date we got your complaint that will give you the results.

If you are not happy with the result of your complaint, you can call us at the toll‑free number on your/your child’s ID card and ask for an appeal. You can also ask for an appeal of a complaint resolution by writing to:

Aetna Better Health
Attention: Member Advocate
PO Box 569150
Dallas, TX 75356‑9150
1‑800‑245‑5380 (Tarrant) or 1‑866‑818‑0959 (Bexar)

Within five (5) days of getting your request for an appeal, the Member Advocate will send you a letter to let you know that your appeal came to us. The Appeal Panel will look over the information you submitted and discuss your/your child’s case. It is not a court of law. You have the right to appear in front of the Appeal Panel at a specified place to talk about the written appeal you sent us. When we make the decision on your appeal, we will send you a response in writing within thirty (30) days after we get the appeal.

If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance by calling toll free to 1-800-252-3439. If you would like to make your request in writing send it to:

Texas Department of Insurance
Consumer Protection
PO Box 149091
Austin, TX 78714-9091

If you can get on the internet, you can send your complaint in an email.

CHIP/CHIP Perinate appeal process

If we deny or limit your doctor’s request for a covered service for your/your child, you have the right to ask for an appeal. You or your child’s doctor can send us more information to show why you do not agree with the decision. You can call us and ask for an appeal. The Member Advocate will write down the information and send it to you to look over. A written appeal can be sent to:

Aetna Better Health
Attention: Member Advocate
PO Box 569150
Dallas, TX 75356‑9150

If your child’s services are denied, you and your child’s doctor will get a letter that tells you the reason for denial. The letter will also tell you how to file an appeal and how to ask for a review by an Independent Review Organization (IRO).

You can appeal a decision to deny services at any time after you are told of the decision. The timeframe for the resolution of the appeal will depend on what services have been denied. If you or your child is in the hospital or is already getting services that are being limited or denied, you can call and ask for an expedited appeal. The expedited appeal process is explained below.

For a standard appeal, the Member Advocate will send you a letter within five (5) days of getting your request for an appeal to let you know that we got it. We will send all available information to a doctor who was not involved in making the first decision. You will get a written response on your appeal within thirty (30) days after we get the appeal.

If you don’t agree with the decision made by us, you can ask us for an appeal. You do not have a right to an appeal if the services you asked for are not covered under the CHIP program or if a change is made to the state or federal law, which affects CHIP members.

Your request does not have to be in writing. You can ask for an appeal by calling us at the toll‑free number listed on your/your child’s ID card and ask for the Member Advocate. We will write down what you tell us and send it to you to review.

You can get help in filing an appeal by calling us at the toll‑free number listed on your/your child’s ID card or writing to:

Aetna Better Health
Attention: Member Advocate
PO Box 569150
Dallas, TX 75356‑9150

The Member Advocate will listen to your appeal and tell you about the rules. The Member Advocate will answer your questions and see that you are treated fairly.