CHIP Complaints and Appeals

Blue Cross and Blue Shield of Texas wants to make sure you are happy with any services provided to you. If you are not happy with care you’ve received or decisions made about your plan coverage, you can file a complaint or appeal.

How to File a Complaint

If you have a complaint about service or care you received, you can file a complaint. You, your provider, or someone you trust can file a complaint with BCBSTX. Check the options below.

What Happens After a Complaint is Filed?

BCBSTX will send you an acknowledgement letter (“Notice of Action” letter) within 5 business days of getting your complaint – we’ll tell you that we received it. If your complaint was received by a phone call, 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 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.

BCBSTX takes member complaints very seriously. We want to know what is wrong so we can make our service better. We have procedures in place to help members who file complaints. If you file a complaint, it will not change your health care or your plan coverage. 

File a Complaint with the Texas Department of Insurance (TDI)

Are you not happy with the way BCBSTX handled your complaint? You can file a complaint with the 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: 

• Submit your complaint to the Consumer Complaint Portal at: tdi.texas.gov
• Call toll-free: 1-800-252-3439
• Email: ConsumerProtection@tdi.texas.gov
• Write to:
  Texas Department of Insurance Consumer Protection
  P.O. Box 149091
  Austin, Texas 78714-9091 

Learn more about the complaint process in the CHIP Member Handbook.

How to File an Appeal

If we do not approve coverage for medical care or medicines, you can file an appeal with BCBSTX. Your health care provider, friend, relative, lawyer or anyone else you choose can file your appeal. 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. 

You must file your appeal within 60 calendar days from the date on the Notice of Action letter.  If you want to continue services during your appeals process, you must ask for this within 10 days after you get the Notice of Action Letter. We will give you a decision on your appeal within 30 days.

Refer to your CHIP Member Handbook to learn more about appeals.

Health Plan Appeals

There are different ways to file an appeal related to your health plan. Check the options below.

Pharmacy Appeals

If you would like to appeal a pharmacy service, you or your provider can:

Learn more about the appeal process in the CHIP Member Handbook.

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 stay in hospital.
• Expedited Appeal: This appeal is available when these are denied: emergency care, a continued stay in hospital, or 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: This type of appeal involves addressing cases with special circumstances. 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 a denied service that involves treatment of a brain injury.

What Happens After an Appeal is Filed?

You and your doctor will get a Notice of Action letter from BCBSTX if we decide not to cover a medical service or medicine. The letter will explain the reason for our denial. This letter will tell you:

• What action was taken and the reason for it
• Your right to file an appeal and how to do it
• Your right to ask for and external review and how to do it
• Your right in some cases to ask for an expedited/emergency appeal and how to do it
• Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services

After you file an appeal, we will call you within 30 days to let you know our decision. We will also send a letter (“Decision Notice “) to you and your authorized representative to let you know the decision.

Expedited Appeals

Do you think the normal 30-calendar-day appeal time will put your health at risk (cause serious harm)? You or your doctor can ask us to “expedite” your appeal (review it faster). 

• Call the Customer Advocate Department at 1-888-657-6061 (TTY: 711)
• Ask for an expedited health plan or pharmacy appeal.

BCBSTX must decide to approve or deny your appeal within 72 hours of your request. If we agree to expedite your appeal, we will tell you/your provider over the phone. We will also send a follow-up letter that tells you the outcome.

Your CHIP plan automatically provides an expedited review for a continued hospital stay and other health care services for a member who has received emergency care and is still in the hospital. 

Independent Review Organization (IRO)

Not happy with the BCBSTX decision on your appeal? You can ask for a review by an IRO. This can be done at no cost to you.

When do you file for review by an IRO? File after you go through the entire BCBSTX appeals process. You do not have to go through the entire BCBSTX 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 IRO before exhausting our internal appeal process, or 
• We decide to waive the appeal process requirements.

How long do you have to file for an IRO? 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 request. You do not have to pay for the review. To request the IRO review, you or someone you trust can fill out the MAXIMUS Federal Services IRO request form. Return it to BCBSTX at:

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 IRO or send the request for an IRO 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 will receive a decision about IRO in no more than 45 days.

Download copies of these forms:

• BCBSTX Health Plan Appeal Request Form
• MAXIMUS Federal Services IRO Request Form

Call if you have a question, want a status or need to get help filing complaints, appeals, and External Medical Reviews by an IRO:

• BCBSTX Customer Advocate Department: 1-888-657-6061 (TTY: 711)
• CHIP Member Advocate: 1-877-375-9097 (TTY: 711).

To find out more about complaints and appeals, please check the Complaints and Appeals section of your CHIP Member Handbook.