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Member Appeals and Complaints

Member Appeals and Complaints

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Appeals Process

Expedited Appeals Process

State Fair Process

Complaints 

  • File a Complaint — If you get benefits through Medicaid’s STAR, STAR+PLUS, or STAR Health program, call your medical or dental plan first. If you don’t get the help you need there, you should do one of the following:

    1. a. Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free)
      b. Online: Online Submission Form
      c. Mail: Texas Health and Human Services Commission 
            Office of the Ombudsman, MC H-700 
            P.O. Box 13247 
            Austin, TX 78711-3247 
      d. Fax: 1-888-780-8099 (Toll-Free)

    Coverage Determinations

    • All denials of services are made by the RightCare Medical Director(s), after review of medical facts given by your provider. Any person making decisions for services makes them based only on the appropriateness of care and services. No rewards are based on review of services or service denials. RightCare does not offer money or rewards, to providers or other people making decisions on services.

    What should I do if I have a complaint?

    • We want to help. If you have a complaint, please call us toll-free at 1-855-897-4448 to tell us about your problem. A RightCare Member Services Advocate can help you file a complaint. Just call 1-855-897-4448. Most of the time, we can help you right away or at the most within a few days. RightCare will acknowledge, investigate, and resolve a complaint within 30 calendar days after the date RightCare receives your complaint.

    What are the requirements and timelines for filing a complaint?

    • You can file a complaint at any time. A complaint can be done over the phone or in writing:

    RightCare from Scott & White Health Plan

    ATTN: Complaints and Appeals 

    MS-A4-144 

    1206 West Campus Drive 

    Temple, TX 76502 

    1-855-897-4448



    What should I do if I am not satisfied with the outcome of my complaint?

    • If you do not feel RightCare gave you the right answer to your complaint, you can appeal the decision to RightCare. See the “Appeal Process” section below for help in filing an appeal or call Member Services at 1- 855-897-4448.

    Can RightCare help me with status questions about the Complaint Process?

    • You can call Member Services at 1-855-897-4448 to get help with status questions.

    Appeals Process

    What can I do if my doctor asks for a service or medicine for me that’s covered but RightCare denies it or limits it?

    • There may be times when RightCare’s Medical Director denies services or medicines. When this occurs, you may appeal this decision. Call Member Services at 1-855-897-4448 to find out more.

    How will I find out if services are denied?

    • RightCare will send you a letter telling you that the services were denied or limited.

    When do I have the right to ask for an appeal?

    • You can appeal a decision if Medicaid covered services are denied based on lack of medical need. You can appeal a denial if you feel RightCare:
    1. denied coverage for care you think should be covered;
    2. stopped care you think you need;
    3. did not pay for services in whole or in part; or
    4. limited a request for a covered service.

    What are the requirements and timelines for filing an appeal?

    • You have thirty (30) calendar days from the date you get the denial letter to send us an appeal. You or your provider may appeal verbally or in writing. If you need more than ten (10) business days to appeal, you may ask for more time. You may have fourteen (14) more calendar days to file the appeal. We will send you a letter within five (5) days of receiving your appeal, to let you know that we got it. We will complete the appeal review within thirty (30) days. If we need more time to review the appeal, we will send you a letter telling you why we need more time. If you wish to appeal a denial of a service that is not a covered benefit, then you will need to file a complaint with the State. See “Complaints Process” section above to see how to file a complaint with the state.

    How can I ask for continuity of current authorized services?

    • If you are receiving services that are being ended, suspended or reduced, you must file an appeal on or before the later of:
    1. denied coverage for care you think should be covered;
    2. stopped care you think you need;
    3. did not pay for services in whole or in part; or
    4. limited a request for a covered service.

    Call RightCare at 1-855-897-4448 for more information.

    Can someone from RightCare help me file an appeal?

  • Yes. A RightCare Member Services Advocate can help guide you through the appeals process. Contact Member Services at 1-855-897-4448 for help.
  • Does my appeal request have to be in writing?

  • You can call Member Services at 1-855-897-4448 to let us know you want to appeal an action, but you must follow up your phone call with a request in writing. If you need help, RightCare can help you write your appeal. Your written appeal should be mailed to:
  •  

    RightCare from Scott & White Health Plan

     ATTN: Complaints and Appeals 

    MS-A4-144 

    1206 West Campus Drive 

    Temple, TX 76502

    When can I request a State Fair Hearing?

  • You can request a State Fair Hearing within 120 days from the date on the Appeal Resolution letter. See the “State Fair Hearing” section below for help in requesting a State Fair Hearing or call Member Services at 1-855-897-4448 for help.
  • Can RightCare help me with status questions about the Medicaid Member Appeals Process?

    • You can call Member Services at 1-855-897-4448 to get help with status questions.

    Expedited Appeals Process

    What is an expedited appeal?

  • An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.
  • How do I ask for an expedited appeal?

  • You can ask for an expedited appeal by calling RightCare Member Services at 1-855-897-4448.
  • Does my request have to be in writing?

  • No, you should submit your expedited appeal request verbally to RightCare Member Services at 1-855-897- 4448. You can request an expedited appeal in writing, but we may be able to help you faster if you call us.
  • What are the timeframes for an expedited appeal?

  • If your expedited appeal is about an ongoing emergency or denial to stay in the hospital, RightCare will review your case and get back to you within one (1) work day after we receive your request. Other expedited appeals will be decided within three (3) days. This process may be extended up to 14 days if more facts are needed.
  • What happens if RightCare denies the request for an expedited appeal?

  • If RightCare decides that your appeal does not need to be expedited, RightCare will let you know right away. The appeal will still be reviewed but the resolution may take up to thirty (30) days.
  • Who can help me file an expedited appeal?

  • You may discuss your request for an expedited appeal with RightCare Member Services at 1-855-897-4448. Requests for expedited appeal are very serious. RightCare wants to make sure you receive the care that is medically necessary. A RightCare Member Services Advocate can help guide you through the expedited appeals process. Contact Member Services at 1-855-897-4448.
  • State Fair Hearing

    Can I ask for a State Fair Hearing?

    • If you, as a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing only after exhausting the MCO Internal Appeal System provided by RightCare. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 120 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 120 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at:

    RightCare from Scott & White Health Plan 

    ATTN: Fair Hearing Request 

    MS-A4-144 

    1206 West Campus Drive 

    Temple, TX 76502  

    OR by phone 1-855-897-4448

      You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made if you ask for a fair hearing by the later of: (1)10 calendar days following MCO’s mailing of the notice of the Action, or (2) the day the health plan’s letter says your service will be reduced or end. If you do not request a fair hearing by this date, the service the health plan denied will be stopped.

      If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.

    Can RightCare help me with status questions about the Fair Hearing Process?

    • You can call Member Services at 1-855-897-4448 to get help with status questions.