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Complaints and Appeals

How to File a Complaint

If you have a complaint about a service or care you received from Blue Cross and Blue Shield of Texas or one of our providers, please call a Customer Advocate at 1-888-657-6061 (TTY: 711). You can file a complaint by phone or ask for a complaint form to be mailed to you.

You can file a complaint if you are having problems with:

  • Access to health care services, 
  • Provider care and treatment, or 
  • Administrative issues.

You have the right to give written comments, documents, or other information for your complaint either by calling or in writing. BCBSTX will send you an acknowledgement letter within 5 business days of our receipt of your complaint telling you that we received it. If your complaint was received orally, the acknowledgement letter will include a complaint form. You can complete the complaint form and return it to us. You can include more information that will help us resolve your complaint.

While BCBSTX is looking into your problem, we will be getting facts from all the parties involved in your complaint. This might include providers, facilities, health plan staff or others. We will look at all of the facts. We will send you a letter with our decision within 30 calendar days of the day we get your complaint in writing. The decision letter will have the reasons why we made the decision.

You, your provider, or someone you trust can file a complaint with BCBSTX. You can submit in the following ways:

  • Write to:
        Blue Cross and Blue Shield of Texas
        Attn: Complaints and Appeals Department
        P.O. Box 660717
        Dallas, TX 75266-0717
  • Call the BCBSTX Customer Advocate Department: 1-888-657-6061 (TTY: 711) 
  • Call CHIP Member Outreach: 1-877-375-9097 (TTY: 711)

Learn more about the complaint process in Part 13 of the CHIP Member Handbook.

Not happy with a decision that was made about your care? You can file a complaint appeal.

You can file an appeal if:

  • You are not getting a service you wanted.
  • You did not get all the services approved that you asked for.
  • You had a service approved before, but now it is ending.
  • It is taking a long time to get the service you asked for.

Your appeal can be filed by your health care provider, friend, relative, lawyer or anyone else you choose. When you file an appeal, we will take another look at your case and see if there is something more we can do to help.

Filing a Complaint Appeal with the Texas Department of Insurance (TDI)

If you are not happy with the way BCBSTX has handled your complaint, you can file a complaint with the Texas Department of Insurance (TDI). You must go through the entire BCBSTX complaint process before you file a complaint with TDI. Learn more about how to file a complaint on the TDI website.

To file a complaint with TDI: 

How to File an Appeal

To request a health plan appeal you can:

  • File a written appeal using the Health Plan Appeal Request Form. Mail or fax it to us using the address or fax number listed at the top of the form. 
  • File an oral appeal by calling the BCBSTX Customer Advocate Department toll-free at 1-888-657-6061 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.  
  • Email to: GPDTXMedicaidAG@bcbsnm.com.
  • Mail to:
    Blue Cross and Blue Shield of Texas
    ATTN: Complaints and Appeals Department
    P.O. Box 660717
    Dallas, TX 75266-0717
  • Call a Member Advocate for help filing an appeal at 1-877-375-9097 (TTY: 711)

You must request an appeal by 60 days from the date your notice for denial of services was mailed. We will give you a decision on your appeal within 30 days.

To request a pharmacy appeal you can:

  • Call the BCBSTX Customer Advocate Department toll-free at 1-888-657-6061 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.
  • Mail a written appeal to:
    Blue Cross and Blue Shield of Texas
    Attn: Prime Therapeutics Appeals Department
    2900 Ames Crossing Road
    Eagan, MN 55121
  • Fax a written appeal to 1-855-212-8110.
  • Have your doctor submit online at MyPrime.com or CoverMyMeds.com.

What kind of appeal should you file?

  • Standard Appeal: An appeal that does not involve urgent care such as emergency care, life threatening conditions, or continued hospitalization.
  • Expedited Appeal: An expedited appeal is available for denial of emergency care, a denial of continued hospitalization, or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient. 
  • Specialty Appeal: The provider of record may request a specialty review the case within 10 working days from the date the appeal was requested or denied. 
  • Acquired Brain Injury Appeal: An appeal of denied services concerning an acquired brain injury.

Expedited Health Plan and Pharmacy Appeal

If you feel your health will be seriously harmed by waiting for a decision on your health plan or pharmacy appeal, you or your doctor can ask for an emergency health plan or pharmacy appeal. If you qualify for an emergency health plan or pharmacy appeal, we must decide to approve or deny your appeal within 72 hours of your request.

Independent Review Organization (IRO)

If you are not happy with the BCBSTX decision on your appeal, you can ask for an immediate external review through an independent review organization at no cost to you. You can file for an external review after you go through the entire BCBSTX appeals process. You do not have to go through the entire internal appeals process before you ask for an IRO review only if:

  • we fail to meet our internal appeal process timelines, or
  • the claimant with an urgent care situation files an external review before exhausting our internal appeal process, or 
  • we decide to waive the appeal process requirements.

You, someone you choose to appeal for you, or the provider named on the appeal, will have 4 months from the date you received the decision notice to file your external review request. You do not have to pay for the review. To request the independent review, you or someone you trust can fill out the Maximus form and return it to BCBSTX:

    Blue Cross and Blue Shield of Texas
    C/O Complaints and Appeals Department
    P.O. Box 660717
    Dallas, TX 75266
    Fax: 1-855-235-1055

The patient, parent, or the patient's legal guardian must also sign the consent to release medical information to the IRO. You, your provider, or someone you trust can call Maximus to request External Medical Review or send the request for an External Medical Review directly to BCBSTX at the address above or to Maximus at:

    MAXIMUS Federal Services
    3750 Monroe Avenue, Suite 705
    Pittsford, NY 14534
    Phone Number: 1-888-866-6205
    Fax number: 1-888-866-6190

You can also download copies of the appeals request form and MAXIMUS Federal Services IRO request form. You will receive a decision in no more than 45 days.

Find out more about filing complaints, appeals, and reviews by an Independent Review Organization by calling one of the following numbers:

For more information about complaints and appeals, please check the Complaints and Appeals section of your CHIP Member Handbook.

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