Texas

STEP ONE – Notify Your Health Plan

The first thing you need to do is file a complaint with your health plan. Follow the steps below to file a complaint and appeal with your health plan:

• Call the member/customer service phone number for your health plan.
• Tell them you want to file a formal complaint and then explain the problem.
• You can also file your complaint by letter, email, or online through your health plan’s website (see below).
• If you disagree with your health plan’s decision, you have the right to an internal appeal.

Below are links to the complaint forms for Texas’ top health plans:

• AmBetter (Superior Health Plan)
• Blue Cross Blue Shield of Texas
• CHRISTUS Health
• Cigna
• Community First
• Community Health Choice
• FirstCare (SHA)
• IdealCare (Sendero)
• Molina
• Oscar
• Prominence Health Plan
• UnitedHealthCare
  • Log on to MyUHC.com and complete the “Appeals and Grievance Form”
  • Select: Claims and Accounts > Medical Appeals and Grievances > Member Service Request Form
  • Fax or mail the completed form to the UnitedHealthcare address listed in the instructions
• My plan isn’t listed

Medicare Plans

 

STEP TWO – File a Complaint

You have the right to file a complaint with the Texas Department of Insurance (TDI) if you have a problem getting the services you need, including quality and affordable health care. To file a complaint you must first complete your health plan’s appeal process.

• File an online complaint here.
• You can also use the complaint form here to send to TDI by email, mail, in person or fax.
• For further information about filing a complaint, call TDI’s helpline: (800) 252-3439.
• After you send your complaint to TDI, they will send you an acknowledgement letter and an explanation of the outcome within 46 days.

If your health plan denied your treatment because it said the treatment wasn’t medically necessary, you may be able to request an Independent Review Organization (IRO) review.

• You must appeal the denial with your health plan before requesting an IRO review.
• To contact TDI’s IRO Information Line call: (886) 554-4926.