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Complaints and appeals

We want you to be happy with the care you get. So if you’re ever unhappy with your health plan or a provider, you can file a complaint. And if you’re unhappy with a decision we made, you can file an appeal. This process helps us make our services better.

 

To learn more, just visit our Materials and forms page to check your member handbook.

I want to file a complaint or an appeal

I want to file a complaint or an appeal

We take your concerns seriously. Just let us know how we can improve our service. There’s no time limit for filing a complaint.

 

You can file an appeal if you don’t agree with a decision we made. You can do this after you receive a Notice of Action letter telling you that we’re denying, delaying, changing or ending a service. The letter tells you how to:

 

  • File an appeal
  • Ask for a state fair hearing

You must file an appeal within 90 days (effective through June 30, 2022) from the date you received your notice. If you’re currently getting treatment and wish to keep doing so, you must file an appeal within 10 calendar days of getting your notice.

 

Choosing someone to act for you

You can have someone you know help you or act on your behalf for a complaint, appeal or state fair hearing. This can be a family member, friend, guardian, lawyer or doctor. Just tell us the person’s name in writing, and how to reach them.

File here

I want to file a complaint or appeal

 

You have options for filing a complaint or appeal. And we’re here to help you through the process. If you don’t speak English, we can provide an interpreter at no cost. 

 
 

After you file your complaint or appeal, we’ll:

 

  • Send you a letter telling you we received your standard complaint or appeal within 5 business days
  • Send another letter telling you the results within 30 calendar days
  • Extend the decision time about your appeal up to 14 days if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. You can also ask for more time if you need it.

Were you satisfied with the process?

STAR and STAR Kids members — did you complete the complaint and appeal process? If you did, but you need more help or you weren’t happy with the results, you can contact HHSC:

 

By phone

Call the Medicaid Managed Care Helpline at 1-866-566-8989.

 

Online

Visit the Health and Human Services Office of the Ombudsman web page.

 

By mail

You can write the HHS Office of the Ombudsman at:

 

Texas Health and Human Services Commission

Office of the Ombudsman, MC H-700

P.O. Box 13247

Austin, TX 78711-3247

 

By fax

You can fax the HHS Office of the Ombudsman at 1-888-780-8099.

You can expedite your appeal if waiting 30 calendar days would harm your health. We’ll make a decision within 72 hours of receiving your appeal. If the appeal is related to an ongoing emergency or denial of a continued hospital stay, we’ll make a decision within 1 business day of receipt.

 

You can submit an expedited appeal: 

 

By phone

 

 

By mail

Write to:
Aetna Better Health of Texas
Attention: Complaints and Appeals
P.O. Box 81139
5801 Postal Rd.
Cleveland, OH 44181

Do you disagree with our decision? You have the right to ask for a state fair hearing.

 

Choosing someone to act for you

You may name someone to act for you by writing us a letter. Tell us the name of the person you want to act for you. It can be a doctor or other medical provider. The person you choose is your representative.

 

Check your timelines

You or your representative must ask for a state fair hearing within 150 days (effective through June 30, 2022) of the date on the health plan’s letter with the appeal decision. What happens if you don’t ask for a state fair hearing in this time frame? You may lose your right to a state fair hearing.

 

You have the right to keep getting any service that we denied or reduced, at least until the decision is made on your state fair hearing. This will happen by whichever of these dates is the latest:

 

  • 10 calendar days after our mailing of the appeal decision letter
  • The day our letter says we’ll reduce or end your service

If you don’t ask for a state fair hearing by this date, the service we denied will stop.

 

You or your representative can ask for a state fair hearing:

 

By mail


Fill out the form that came with resolution of your appeal notice. Or download the state fair hearing form (English PDF/Spanish PDF) and send it to:

 

Aetna Better Health of Texas

Attention: Complaints and Appeals

P.O. Box 81139

5801 Postal Road

Cleveland, OH 44181

 

By phone

 

Call us:

 

If we deny services, you and your doctor will get a letter that tells you the reason for denial. The letter will also tell you about your options and next steps.

 

At any time, you can ask questions or check the status of your:

 

  • Complaint
  • Appeal
  • State fair hearing

Just contact us.

I want to file a complaint or an appeal

I want to file a complaint or an appeal

We take your concerns seriously. Let us know how we can improve our service. There’s no time limit for filing a complaint.

 

You can file an appeal if you don’t agree with a decision we made. File your appeal after you receive a Notice of Action letter telling you that we’re denying, delaying, changing or ending a service. The letter tells you how to:

 

  • File an appeal
  • Ask for an independent review

 

You must file an appeal within 90 days (effective through April 30, 2022) from the date you received your notice. If you’re currently getting treatment and wish to keep doing so, you must file an appeal within 10 calendar days of getting your notice.

 

You don’t have the right to an appeal if:

 

  • The services you asked for aren’t part of your coverage
  • A change is made to the state or federal law, which may affect coverage

 

Choosing someone to act for you

You can have someone you know help you or act on your behalf for a complaint, appeal or state fair hearing. This can be a family member, friend, guardian, lawyer or doctor. Just tell us the person’s name in writing, and how to reach them.

File here

I want to file a complaint or appeal

 

You have options for filing a complaint or appeal. And we’re here to help you through the process. If you don’t speak English, we can provide an interpreter at no cost. 

 
 

After you file your complaint or appeal, we’ll:

 

  • Send you a letter telling you we received your standard complaint or appeal within 5 business days
  • Send another letter telling you the results within 30 calendar days
  • Extend the decision time about your appeal up to 14 days if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. You can also ask for more time if you need it.

Within 5 business days of getting your complaint appeal, we’ll send you a letter saying that we received it. You have the right to appear before the panel at a specific place to talk about your complaint. It’s not a court of law.

 

The Complaint Appeal Panel will review and discuss your case. Once we decide on your appeal, we’ll send you a response in writing. This will be within 30 days after we get your appeal.

 

If you aren’t satisfied with the answer to your complaint, you can also contact the Texas Department of Insurance:

 

By phone: 1-800-252-3439. The help line is open Monday to Friday, 8 AM to 5 PM CT.

 

By fax: 512-475-1771

 

Online: Just visit the Texas Department of Insurance to get help with an insurance complaint

 

By mail:

Texas Department of Insurance
Consumer Protection
MC 111-1A

PO Box 149091
Austin, TX 78714-9091

You can expedite your appeal if waiting 30 calendar days would harm your health. We’ll make a decision within 72 hours of receiving your appeal. If the appeal is related to an ongoing emergency or denial of a continued hospital stay, we’ll make a decision within 1 business day of receipt.

 

You can submit an expedited appeal:

 

By phone

 

 

By mail

Aetna Better Health of Texas

Attention: Complaints and Appeals

P.O. Box 81139

5801 Postal Rd.

Cleveland, OH 44181

You or your representative have the right to a no-cost, independent external review within four months after the date of the letter. This review isn’t connected with Aetna Better Health of Texas or any of your health care providers. To ask for an independent external review, complete the Health and Human Services Federal External Review Request Form (PDF).

You can submit the form: 

 

Online: Choose “Request a Review Online.”

By fax: 1-888-866-6190

By mail:

MAXIMUS Federal Services

3750 Monroe Avenue, Suite 705

Pittsford, NY 14534

 

Expedited independent review of appeals

You or your representative can ask for an external review of your appeal right away if waiting for a decision would cause you harm. You can ask for an expedited external review:

 

By email: Send the request to FERP@Maximus.com.

By phone: Call MAXIMUS Federal Services at 1-888-866-6205 (extension 3326).

Online: Choose “Request a Review Online” and “Expedited.”

 

In urgent situations, MAXIMUS Federal Services will accept a request for external review from a health care provider. The provider should know about the member’s condition. 

If we deny services, you and your doctor will get a letter that tells you the reason for denial. The letter will also tell you about your options and next steps.

 

At any time, you can ask questions or check the status of your:

 

  • Complaint
  • Appeal
  • Complaint review panel
  • Independent review

Just contact us.