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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

The appeals process and your rights

Sometimes, we make decisions about care and services you or your provider asks us to approve. When we decide to deny or reduce a service, you may ask for an appeal. During an appeal, a doctor or other qualified reviewer, not involved in the original decision, looks again at your case. He or she will review all the information about your appeal and make an appeal decision.

Requesting an appeal

You must ask for an appeal in writing within 60 days of the date on the decision letter. You can also ask your provider or another person to appeal for you.

You can appeal 2 ways:

  • Send a letter or an Appeal Form to:
    Amerigroup Appeals
    2505 N. Highway 360, Suite 300
    Grand Prairie, TX 75050
  • 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.

If you request an appeal by phone, you must still follow up in writing (unless you asked for an expedited appeal). We’ll send you an appeal form in the mail. Fill it out and return it to the address above within 60 days of the date on our decision letter.

  • We’ll send you a letter with our appeal decision within 30 calendar days of getting your written request.

Call Member Services toll-free at 1-800-600-4441 (TTY 711) for status updates on your appeal, or if you have questions about the appeal process. STAR Kids members, call 1-844-756-4600 (TTY 711).

If your appeal involves services we previously approved and are now reducing or ending, you may be able to keep getting those services while your appeal is pending. To do so, you must file the appeal before the later of the two dates below:

  • Ten days after the date we send you the denial notice, or
  • The day our letter says your service will end or be reduced

If we uphold our decision to deny or reduce services, 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.

Call Member Services toll-free at 1-800-600-4441 (TTY 711) for status updates on your appeal, or if you have questions about the appeal process. STAR Kids members, call 1-844-756-4600 (TTY 711).

Requesting a State Fair Hearing

If you disagree with our appeal decision, you have the right to ask for a Medicaid State Fair Hearing from the Texas Health and Human Services Commission (HHSC). You must request a State Fair Hearing within 120 calendar days of the date on our appeal decision letter. If you don’t get an appeal decision within the required time frame, you can ask for a State Fair Hearing without getting our appeal decision.

You can ask for an expedited State Fair Hearing due to an emergency or life-threatening situation.

To ask for a State Fair Hearing, you or someone on your behalf should do one of the following:

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

If you ask for a fair hearing within 10 days from the date we sent the appeal decision letter, you may be able to keep getting the service or benefit, at least until the final hearing decision is made. If the State Fair Hearing upholds our decision to deny or reduce services, you may have to pay for any services you kept getting.

If you ask for a State Fair Hearing, we’ll send you a packet of information telling you the date, time, and location of the hearing. Most State 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 at 1-800-600-4441 (TTY 711). STAR Kids members, call 1-844-756-4600 (TTY 711).

Your decision to ask for an appeal or a State 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.