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Your rights as our member

The best place to learn about your rights as our member is to read the member handbook. Your member handbook will tell you more about your rights to file a complaint or an appeal. If you have questions about anything you read here or in the member handbook, call Member Services.You can learn about your rights and responsibilities by reading the document for your plan below:

Member advocates are here for you

Our member advocates will help you if you’re having trouble getting services. Call Member Services and ask to speak with one.

Filing a complaint

If you’re unhappy about a decision we made or care you received, you have the right to file a complaint.

You can file a complaint with us, the Health and Human Services Commission, or the Department of Aging and Disability Services. You can tell us your complaint by phone or in writing:

  • To file a complaint by phone, call Member Services toll-free at 1-800-600-4441. For STAR Kids members, call Member Services at 1-844-756-4600 (TTY 711).
  • To file in writing, send a letter or use the complaint form
    to:

Member Advocates
Amerigroup
823 Congress Ave., Suite 400
Austin, TX 78701

If you want help filing a complaint, call Member Services and a representative will be glad to help you.

We’ll send you a letter within 5 business days of getting your complaint. It will tell you we’ve received your complaint and have started to look at it. If your complaint was made by phone, the letter will include a complaint form (STAR Kids members use this form). You must fill out this form and mail it back to us at the address above. If you need help filling out the complaint form, call Member Services.

What happens after I make a complaint?

We’ll send you a letter within 30 days of getting your complaint. The letter will tell you what we have done to address your complaint.

If it’s about an ongoing emergency or hospital stay, it will be resolved as quickly as needed for the urgency of your case and no later than 1 business day from when we receive it. If you have any questions while you’re waiting for our answer, please call Member Services.

If you’re not happy with our answer to your complaint, you can get more help from Texas Health and Human Services Commission. See below for information on how to get help from the state for your plan.

STAR, STAR+PLUS, and STAR Kids members

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

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

CHIP and CHIP Perinatal members

Send complaints to the Texas Department of Insurance.

  • Call 1-800-252-3439
  • Mail your complaint to:
    Texas Department of Insurance
    Consumer Protection
    PO Box 149091
    Austin, TX 78714-9091
  • File Online

Your decision to file a complaint won’t affect your ability to access quality care.

Filing an appeal: STAR, STAR+PLUS, STAR Kids

If we tell you we won’t pay for recommended care and services, you can file an appeal.

An appeal is when you ask us to look again at care your doctor asked for and we said we wouldn’t pay for. You must appeal within 30 days of the date you get our first letter telling you we won’t pay for all or part of the recommended care. You can also ask your doctor or another person to appeal for you.

You can appeal 2 ways:

  • Call Member Services at 1-800-600-4441 (TTY 711). STAR Kids members call 1-844-756-4600 (TTY 711). Tell us you want to file an appeal.
  • Send a letter or an Appeal Form to:

Amerigroup Appeals
2505 N. Highway 360, Suite 300
Grand Prairie, TX 75050

If you appeal by phone, you must still send your appeal in writing unless you asked for an expedited appeal. We’ll send you an appeal form in the mail. Fill it out and send it to the address above within 30 days of the date you received our denial letter.

If your appeal involves services we previously approved and are now reducing or ending, you can ask to keep getting those services while your appeal is pending. You must file the appeal before the later of the two dates below:

  • Within 10 days after we mail you the notice saying we won’t pay for all or part of the currently approved care, or
  • The day our letter says your service will be reduced or end

We’ll send you a letter with the answer to your appeal within 30 calendar days from when we get your appeal.

If we deny your appeal, you may have to pay for any services you kept getting.

Learn more about the appeal process, including expedited appeals for emergency or life-threatening situations, by reading the member handbook.

You can ask for a state fair hearing

You can ask for a state fair hearing anytime during or after we make a decision on your appeal unless you asked for an expedited appeal. You must request a state fair hearing within 90 calendar days of the date on our letter saying we won’t pay for the service.

To ask for a fair hearing, you or someone on your behalf should do one of the following:

  • Send a letter or a Fair Hearing form to:
    Fair Hearing Coordinator
    Amerigroup
    3800 Buffalo Speedway, Suite 400
    Houston, TX 77098
  • Call Member Services at 1-800-600-4441 (TTY 711) or STAR Kids Member Services at 1-844-756-4600 (TTY 711)

    • You can keep getting any service we denied or reduced until the final hearing decision is made if you ask for a fair hearing before the later of the two dates below:

      • Within 10 calendar days after we mailed the letter saying we would not pay for the service, or
      • The day our letter says your service will be reduced or end

      If you ask for a fair hearing, we will send you a packet of information telling you the date, time, and location of the hearing. Most fair hearings are held by telephone, so you won’t need to attend in person. HHSC will give you a final decision within 90 days from the date you asked for the hearing. If you have any questions during the process, please call Member Services.

      Your decision to ask for an appeal or a fair hearing won’t affect your ability to access quality care.

Filing an appeal: CHIP and CHIP Perinate

If we tell you we won’t pay for all or part of the care your doctor recommended, you can appeal.

An appeal is when you ask us to look again at the care we said we won’t pay for. You must submit your appeal within 30 days of the date on our first denial letter. You can also ask your doctor or another person to appeal for you.

You can appeal our decision by phone or in writing:

Amerigroup Appeals
2505 N. Highway 360, Suite 300
Grand Prairie, TX 75050

We’ll send you a letter with the answer to your appeal. We’ll do this within 30 calendar days from the time we get your appeal except for urgent appeals and certain other types of appeals that need a quicker decision.

If you aren’t happy with our decision, the provider can send us a letter to ask for a second level appeal/specialty review. This letter must be sent within 10 business days from the date on our letter with the answer to your first level appeal.

You can ask for an independent review after either your first appeal or a second level specialty review.

Independent reviews

If we still won’t pay for care after a first level appeal or a specialty review, you can ask for an independent review by an Independent Review Organization (IRO). An IRO is not a part of Amerigroup.

To ask for an independent review, you must fill out and send a Request for a Review by an Independent Review Organization (IRO) form to:

Amerigroup Appeals
2505 N. Highway 360, Suite 300
Grand Prairie, TX 75050

When we get your form, we’ll tell the Texas Department of Insurance (TDI) you have asked for an independent review, TDI will send you a letter telling you the name of the IRO looking at your case. The IRO will send you a letter telling you the final decision.

Your decision to file an appeal or ask for an independent review won’t affect your ability to get quality health care.

To learn more about the appeal process, expedited appeals, and second level specialty reviews, read the member handbook.