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I want to file a complaint or an appeal
I want to file a complaint or an appeal
We take your concerns seriously. Just let us know how we can improve our service. There’s no time limit for filing a complaint.
You can file an appeal if you don’t agree with a decision we made. You can do this after you receive a Notice of Action letter telling you that we’re denying, delaying, changing or ending a service. The letter tells you how to:
- File an appeal
- Ask for a state fair hearing
You must file an appeal within 60 days from the date of the notice. If you’re currently getting treatment and wish to keep doing so, you must file an appeal within 10 calendar days of getting your notice.
Choosing someone to act for you
You can have someone you know help you or act on your behalf for a complaint, appeal or state fair hearing. This can be a family member, friend, guardian, lawyer or doctor. Just tell us the person’s name in writing, and how to reach them.
After you file your complaint or appeal, we’ll:
- Send you a letter telling you we received your standard complaint or appeal within 5 business days
- Send another letter telling you the results within 30 calendar days
- Extend the decision time about your appeal up to 14 days if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. You can also ask for more time if you need it.
Were you satisfied with the process?
STAR and STAR Kids members — did you complete the complaint and appeal process? If you did, but you need more help or you weren’t happy with the results, you can contact HHSC:
By phone
Call the Medicaid Managed Care Helpline at 1-866-566-8989.
Online
Visit the Health and Human Services Office of the Ombudsman web page.
By mail
You can write the HHS Office of the Ombudsman at:
Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
By fax
You can fax the HHS Office of the Ombudsman at 1-888-780-8099.
You can expedite your appeal if waiting 30 calendar days would harm your health. We’ll make a decision within 72 hours of receiving your appeal. If the appeal is related to an ongoing emergency or denial of a continued hospital stay, we’ll make a decision within 1 business day of receipt.
You can submit an expedited appeal:
By phone
- STAR (Bexar): 1-800-248-7767 (TTY: 711)
- STAR (Tarrant) 1-800-306-8612 (TTY: 711)
- STAR Kids: 1-844-STRKIDS (1-844-787-5437) (TTY: 711)
By mail
Write to:
Aetna Better Health of Texas
Attention: Complaints and Appeals
P.O. Box 81139
5801 Postal Rd.
Cleveland, OH 44181
Do you disagree with our decision? You have the right to ask for an external medical review (EMR) before you ask for a state fair hearing. You don’t have to ask for an EMR. You can ask for a state fair hearing only.
Choosing someone to act for you
You may name someone to act for you by writing us a letter. Tell us the name of the person you want to act for you. It can be a doctor or other medical provider. The person you choose is your representative.
Check your timelines
You or your representative must ask for a state fair hearing with or without an EMR within 120 days of the date on the health plan’s letter with the appeal decision. What happens if you don’t ask for a state fair hearing in this time frame? You may lose your right to a state fair hearing.
You have the right to keep getting any service that we denied or reduced, at least until the decision is made on your state fair hearing. This will happen by whichever of these dates is the latest:
- 10 calendar days after our mailing of the appeal decision letter
- The day our letter says we’ll reduce or end your service
If you don’t ask for a state fair hearing by this date, the service we denied will stop.
The EMR process
Texas Health and Human Services Commission (HHSC) will give your case to independent health care experts for review. They only use the info from your health plan appeal. So, you won’t be able to give new info for the review.
These experts can agree with or change our decision. They’ll mail the EMR decision to you in 10 calendar days or less. After you get your EMR decision, you can choose if you also want to have the state fair hearing you asked for.
If the EMR agrees with your request
We’ll approve the services within 72 hours of receiving the EMR response.
If the EMR doesn’t agree with your request
HHSC will continue with the state fair hearing review. If you don’t want to continue with a state fair hearing, you have the right to withdraw your request.
You or your representative can ask for a state fair hearing or EMR:
By mail
Fill out the form that came with resolution of your appeal notice. Or download the state fair hearing/EMR form (English PDF/Spanish PDF) and send it to:
Aetna Better Health of Texas
Attention: Complaints and Appeals
P.O. Box 81139
5801 Postal Road
Cleveland, OH 44181
By phone
Call us:
- STAR: 1-800-248-7767 (TTY: 711) (Bexar area)
- STAR 1-800-306-8612 (TTY: 711) (Tarrant area)
- STAR Kids: 1-844-787-5437 (TTY: 711)
If we deny services, you and your doctor will get a letter that tells you the reason for denial. The letter will also tell you about your options and next steps.
At any time, you can ask questions or check the status of your:
- Complaint
- Appeal
- External medical review (EMR)
- State fair hearing
Just contact us.
I want to file a complaint or an appeal
I want to file a complaint or an appeal
We take your concerns seriously. Let us know how we can improve our service. There’s no time limit for filing a complaint.
You can file an appeal if you don’t agree with a decision we made. File your appeal after you receive a Notice of Action letter telling you that we’re denying, delaying, changing or ending a service. The letter tells you how to:
- File an appeal
- Ask for an independent review
You must file an appeal within 60 days from the date you received your notice. If you’re currently getting treatment and wish to keep doing so, you must file an appeal within 10 calendar days of getting your notice.
You don’t have the right to an appeal if:
- The services you asked for aren’t part of your coverage
- A change is made to the state or federal law, which may affect coverage
Choosing someone to act for you
You can have someone you know help you or act on your behalf for a complaint, appeal or state fair hearing. This can be a family member, friend, guardian, lawyer or doctor. Just tell us the person’s name in writing, and how to reach them.
After you file your complaint or appeal, we’ll:
- Send you a letter telling you we received your standard complaint or appeal within 5 business days
- Send another letter telling you the results within 30 calendar days
- Extend the decision time about your appeal up to 14 days if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. You can also ask for more time if you need it.
Within 5 business days of getting your complaint appeal, we’ll send you a letter saying that we received it. You have the right to appear before the panel at a specific place to talk about your complaint. It’s not a court of law.
The Complaint Appeal Panel will review and discuss your case. Once we decide on your appeal, we’ll send you a response in writing. This will be within 30 days after we get your appeal.
If you aren’t satisfied with the answer to your complaint, you can also contact the Texas Department of Insurance:
By phone: 1-800-252-3439. The help line is open Monday to Friday, 8 AM to 5 PM CT.
By fax: 512-475-1771
Online: Just visit the Texas Department of Insurance to get help with an insurance complaint.
By mail:
Texas Department of Insurance
Consumer Protection
MC 111-1A
PO Box 149091
Austin, TX 78714-9091
You can expedite your appeal if waiting 30 calendar days would harm your health. We’ll make a decision within 72 hours of receiving your appeal. If the appeal is related to an ongoing emergency or denial of a continued hospital stay, we’ll make a decision within 1 business day of receipt.
You can submit an expedited appeal:
By phone
- CHIP/CHIP Perinatal (Bexar): 1-866-818-0959 (TTY: 711)
- CHIP/CHIP Perinatal (Tarrant): 1-800-245-5380 (TTY: 711)
By mail
Aetna Better Health of Texas
Attention: Complaints and Appeals
P.O. Box 81139
5801 Postal Rd.
Cleveland, OH 44181
You or your representative have the right to a no-cost, independent external review within four months after the date of the letter. This review isn’t connected with Aetna Better Health of Texas or any of your health care providers. To ask for an independent external review, complete the Health and Human Services Federal External Review Request Form (PDF).
You can submit the form:
Online: Choose “Request a Review Online.”
By fax: 1-888-866-6190
By mail:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Expedited independent review of appeals
You or your representative can ask for an external review of your appeal right away if waiting for a decision would cause you harm. You can ask for an expedited external review:
By email: Send the request to FERP@Maximus.com.
By phone: Call MAXIMUS Federal Services at 1-888-866-6205 (extension 3326).
Online: Choose “Request a Review Online” and “Expedited.”
In urgent situations, MAXIMUS Federal Services will accept a request for external review from a health care provider. The provider should know about the member’s condition.
If we deny services, you and your doctor will get a letter that tells you the reason for denial. The letter will also tell you about your options and next steps.
At any time, you can ask questions or check the status of your:
- Complaint
- Appeal
- Complaint review panel
- Independent review
Just contact us.