Blue Access for Members
blue access for members log in

Complaints and Appeals

Complaints

If you have a complaint about a service, care you received, or an In-Lieu-Of service 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 STAR Member Outreach at: 1-877-375-9097 (TTY: 711)

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

Filing a Complaint with HHSC

If you are not happy with the way BCBSTX has handled your complaint, you can file a complaint with the Texas Health and Human Services Commission (HHSC). You must go through the entire BCBSTX complaint process before you file a complaint with HHSC. Review the HHSC How to Submit a Complaint flyer to find out how to file a complaint.

To file a complaint with HHSC: 

  • Call toll-free: 1-866-566-8989
  • Submit in writing to: 
    Texas Health and Human Services Commission 
    Ombudsman Managed Care Assistance Team 
    P.O. Box 13247 
    Austin, Texas 78711-3247  
  •  Submit your complaint online: hhs.texas.gov/managed-care-help  

Appeals

If we do not approve coverage for a medical service, In-Lieu-Of Services and Settings or payment for service or medicine, in whole or in part that your doctor suggests, we will send you and your doctor a letter to explain the reason for our denial. 

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. To file an appeal, you may:

You must file a request for an appeal with us within 60 days after you get 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. Learn more about the appeals process in Part 13 of the STAR Member Handbook.

Pharmacy Appeals 

If you have a pharmacy appeal:

  • Call the 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. 

Emergency Health Plan or 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.

State Fair Hearings (SFH)

If your appeal is denied, you have the right to ask for either a non-emergency SFH, or an 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 State Fair Hearing 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 Part 13 ("How to Resolve a Problem with BCBSTX") of the STAR Member Handbook.

External Medical Reviews (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 Part 13 (“How to Resolve a Problem with BCBSTX”) of the STAR Member Handbook.

How to ask for an External Medical Review or a State Fair Hearing

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 1-888-657-6061 (TTY: 711).

You can get help filing complaints, appeals, emergency appeals, state fair hearings and external medical reviews by calling one of the following numbers:

For more information regarding Complaints, Appeals and the State Fair Hearing, please check Your Rights for an Appeal of an Adverse Determination and the Complaints and Appeals section of your Member Handbook.

Find a Doctor or Hospital

Use Provider Finder® to search for doctors and other health care providers near you.

Contact Us