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.

Cómo Presentar una Queja

If you have a complaint about service or care you received, you can file a complaint. Usted, su prestador de servicios médicos o alguien en quien confíe pueden presentar una queja ante BCBSTX. Consulte las opciones a continuación.

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. Puede completar el formulario de quejas y devolvérnoslo. Puede incluir más información que nos ayudará a resolver su queja.

Mientras BCBSTX investiga su problema, obtendremos datos de todas las partes involucradas en su queja. Esto podría incluir profesionales médicos, centros, personal de la cobertura médica u otros. We will look at all the facts. Le enviaremos una carta con nuestra decisión dentro de los 30 días calendario a partir del día en que recibamos su queja por escrito. La carta de decisión incluirá las razones por las que tomamos la decisión.

BCBSTX toma muy seriamente las quejas de sus asegurados. Queremos saber cuál es el problema para poder mejorar nuestros servicios. Contamos con procedimientos para ayudar a los asegurados que presentan quejas. Si presenta una queja, esta no cambiará su atención médica ni su cobertura. 

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. Debe pasar por todo el proceso de quejas de BCBSTX antes de presentar una queja ante el Departamento de Seguros de Texas. Learn more about how to file a complaint on the TDI website.

Para presentar una queja ante el Departamento de Seguros de Texas: 

• Presente su queja en el Portal de Quejas del Consumidor en: tdi.texas.gov
• Llame sin cargo: 1-800-252-3439
• Correo electrónico: ConsumerProtection@tdi.texas.gov
• Escriba a:
  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.

Cómo Presentar una Apelación

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. Cuando usted presente una apelación, volveremos a estudiar su caso y veremos si podemos hacer algo más para ayudarlo.

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. Consulte las opciones a continuación.

Apelaciones de farmacia

Si desea presentar una apelación contra un servicio de farmacia, usted o su profesional médico pueden hacer lo siguiente:

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.

¿Qué sucede después de presentar una apelación?

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. En la carta, se le informará lo siguiente:

• qué acción se realizó y la razón de la misma;
• su derecho a presentar una apelación y cómo hacerlo;
• 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
• su derecho a solicitar que sus beneficios continúen durante su apelación, cómo hacerlo y en qué circunstancias podría tener que hacerse cargo del pago de los servicios.

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.

Apelaciones aceleradas

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). 

• Llame al departamento de especialistas en Servicio al Cliente al 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. 

Organización revisora independiente (IRO, en inglés)

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. No tiene que pagar por la revisión. To request the IRO review, you or someone you trust can fill out the el formulario de solicitud de IRO de MAXIMUS Federal Services. 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

El paciente, padre o tutor legal del paciente también debe firmar el consentimiento para divulgar información médica a la 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

Número de teléfono: 1-888-866-6205
Número de fax: 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 to find out more about filing complaints, appeals, and reviews by an IRO:

• Departamento de Especialistas en Servicio al Cliente de BCBSTX: 1-888-657-6061 (TTY: 711)
• Asesor para asegurados de CHIP: 1-877-375-9097 (TTY: 711).

To find out more about complaints and appeals, please check the Quejas y apelaciones del Manual para asegurados de CHIP.