STAR and STAR Kids 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 a service, care you received, or In-Lieu-Of Services and Settings from Blue Cross and Blue Shield of Texas, you can file a complaint. You, your provider, or someone you trust can do this. Check the options below.

What Happens After a Complaint is Filed?

BCBSTX will send you an acknowledgement letter (“Notice of Action”) 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 Health and Human Services Commission (HHSC)

If you receive benefits through Medicaid’s STAR or STAR Kids Program, call BCBSTX first. If you don’t get the help you need there, you should do one of the following:

• Call: Medicaid Managed Care Helpline at 1-866-566-8989 (toll-free)
• Online: Go to the HHSC Ombudsman website
• Mail:
  Texas Health and Human Services Commission
  Office of the Ombudsman, MC H-700
  P.O. Box 13247
  Austin, TX 78711-3247
• Fax: 1-888-780-8099 (toll-free)

Learn more about the complaint process in your plan’s Member Handbook.

How to File an Appeal

If we do not approve coverage for a medical service or medicine, or for In-Lieu-Of Services and Settings, 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.

Health Plan Appeals

You can file an appeal related to your health plan care or a change to your In-Lieu-Of Services and Settings. There are different ways to file an appeal. 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 your Member Handbook.

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 take 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. 

Emergency 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). This is known as an Emergency Appeal. 

Call the Customer Advocate Department for your plan. Ask for an emergency appeal. Be sure to say if it is for an appeal for health care or prescription drugs. 

• STAR, call 1-888-657-6061 (TTY: 711). 
• STAR Kids, call  1-877-688-1811 (TTY: 711). 

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

State Fair Hearings (SFH)

If your appeal is denied, you have the right to ask for either a non-emergency SFH, or Emergency SFH. A SFR is when HHSC directly reviews the decision BCBSTX made about your medical care. 

You or your representative must ask for a SFH within 120 days of the date listed on the health plan’s Notice of Action letter that gives you the internal appeal decision. If you do not ask for a SFH within 120 days, you may lose your right to a review. HHSC will give you a final decision within 90 days from the date you asked for the hearing. If you want to keep getting your services during the SFH process, you must ask for this within 10 days after you get the Notice of Action Letter.

Learn more about how to ask for a SFH and how to keep your services until the final decision is made on your case in the “How to Resolve a Problem with BCBSTX” section of your Member Handbook.  

External Medical Review (EMR) by Independent Review Organization (IRO)

Not happy with the BCBSTX decision on your appeal? You can ask for an EMR. This can be done through an IRO 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 EMR before exhausting our internal appeal process, or
• We decide to waive the appeal process requirements.

How long do you have to file for an EMR?

If you disagree with BCBSTX’s internal appeal decision, you also have the right to ask for an EMR. An EMR is an optional, extra step the member can take to get their case reviewed by and Independent Review Organization (IRO) before the SFH occurs. An IRO is a third-party organization contracted by HHSC that conducts EMR during member appeal processes related to a medical service that is denied, changed, or reduced. 

You or your representative must ask for an EMR within 120 days of the date listed on the health plan’s Notice of Action letter that gives you the internal appeal decision. If you do not ask for an EMR within 120 days, you may lose your right to a review.  

You may withdraw your request for an EMR before it is assigned to an IRO or while the IRO is reviewing the EMR request. The request cannot be withdrawn after the IRO makes a decision. You can withdraw your request for a SFH after the EMR decision is received. If you want to keep getting your services during the EMR process, you must ask for this within 10 days after you get the Notice of Action Letter.   

Learn more about how to ask for an EMR and how to keep your services until the final decision is made on your case in the “How to Resolve a Problem with BCBSTX” section of your Member Handbook.  

How to ask for EMR or SFH

Fill out the State Fair Hearing and External Medical Review Request Form. 

• Mail to:
  Blue Cross and Blue Shield of Texas
  Attn: Complaints and Appeals Department
  P.O. Box 66071
  Dallas, Texas 75266-0717 
• Fax to: 1-855-235-1055
• Email us at: GPDTXMedicaidAG@bcbsnm.com
• Or call BCBSTX at your health plan’s Customer Advocate number below. 

If you have questions, want a status or need to get help filing complaints, appeals, emergency appeals, state fair hearings and external medical reviews, call one of the following numbers:

• STAR Customer Advocate Department: 1-888-657-6061 (TTY: 711). 
• STAR Kids Customer Advocate Department: 1-877-688-1811 (TTY: 711). 
• STAR and STAR Kids Member Advocate in Travis Service Area: 1-877-375-9097 (TTY: 711). 
• STAR Kids Member Advocate in Central Service Delivery Area: 1-855-497-0857 (TTY: 711). 

Want to learn more about complaints and appeals?

Find out about the appeal rights for your plan: 

• STAR and STAR Kids – Your Rights for an Appeal

For more information about complaints, appeals or the State Fair Hearing, you can also refer to the Complaints and Appeals section of your plan’s Member Handbook.