06/24/2025
Our Quality Improvement team investigates potential quality of care complaints or deficiencies in clinical care involving participating providers, as reported by providers, service coordinators, case management and Medicaid members or their authorized representatives. Reporting these concerns helps ensure our members receive the best quality of care and most efficient experience.
What is a potential quality of care concern? It is a dissatisfaction with the quality of clinical care rendered in individual occurrences. Medical concerns may include but aren’t limited to:
- A condition that was not appropriately diagnosed
- A condition that was not appropriately treated
- A member had to obtain care elsewhere because of dissatisfaction or concern about care received from a contracted provider or facility
- Medication or treatment errors
- Delayed referrals
- Incidents affecting patient safety
How to file a potential quality of care concern with us: Submit the concern to our appeals and grievance team via:
- Fax to 1-855-235-1055, or
Report abuse to the Texas Department of Family and Protective Services:
- Online
- By phone for urgent matters: 800-252-5400, or
- Online for non-urgent situations
Resources
Review the following resources supporting quality care for Medicaid providers:
- Preventive Care Guidelines
- Clinical Practice Guidelines
- ImmTrac2
- Quality Improvement Tool
- Texas Health Steps
If you have questions, contact our Quality Improvement Team.