Complaints & Appeals
Complaints & Appeals
Provider complaints
Dell Children’s Health Plan accepts provider complaints orally, as well as via mail, fax and email. Oral complaints may be submitted through Provider Services at 1-844-781-2343 or through local Provider Relations representatives. Written provider complaints should be mailed to the following address:
Dell Children’s Health Plan
Attn: Complaints
PO Box 37502
Oak Park, MI 48237-0502
Written complaints can also be sent via email to DCHPComplaints@ascension.org or faxed to 512-855-4909.
Dell Children’s Health Plan will contact the complainant by telephone, email or in writing within 30 calendar days of receipt of the complaint with the resolution.
Provider claim payment disputes and appeals
The information below is a summary of each process. For full details, refer to the provider manual or the Dell Children’s Health Plan provider portal.
Provider claim payment disputes
If you disagree with the outcome of a claim, you may use the Dell Children’s Health Plan provider claim payment dispute process. The simplest way to define a claim payment dispute is when a claim is finalized, but you disagree with the outcome.
The Dell Children’s Health Plan provider claim payment dispute process consists of two internal options. You will not be penalized for filing a claim payment dispute, and no action is required by the member:
- Claim payment reconsideration: This is a convenient option in the Dell Children’s Health Plan provider claim payment dispute process. The reconsideration is an initial request for an investigation into the outcome of the claim. Most issues are resolved with a claim payment reconsideration.
- Claim payment appeal: This is an additional option in the Dell Children’s Health Plan provider claim payment dispute process. If you disagree with the outcome of a reconsideration or you choose not to ask for a reconsideration, you may request a claim payment appeal. Please note: If you did not ask for a claim payment reconsideration first, this will be the only internal appeal option available for you.
Claim payment reconsideration
The first available option in the Dell Children’s Health Plan claim payment dispute process is called the reconsideration. It is your initial request to investigate the outcome of a finalized claim. Please note: We cannot process a reconsideration without a finalized claim on file.
We accept reconsideration requests in writing, verbally or online through the provider portal on the Dell Children’s Health Plan website within 120 calendar days from the date on the Explanation of Payment (EOP). See below for further details on how to submit.
Reconsiderations filed more than 120 calendar days from the EOP will be considered untimely and denied unless good cause can be established. Dell Children’s Health Plan will resolve the claim payment reconsideration within 30 calendar days of receipt.
Claim payment appeal
- 30 calendar days from the date on the reconsideration determination letter, or
- 120 calendar days from the date of the original EOP
How to submit a claim payment dispute
You have several options to file a claim payment dispute:
- Online (for reconsiderations and claim payment appeals): Online through the provider portal on the Dell Children’s Health Plan website. Through the provider portal, you can upload supporting documentation and will receive immediate acknowledgement of your dispute. You may select the type of dispute: claim reconsideration, overpayment dispute or claim appeal
- Verbally (for reconsiderations only): Call Provider Services at 1-844-781-2343.
- Written (for reconsiderations and claim payment appeals):
Mail all required documentation, including the Provider Payment Dispute and Correspondence Submission Form to
Dell Children’s Health Plan
Payment Dispute Unit
P.O Box 37502
Oak Park, MI 48237-0502 - Or fax form to 1-586-693-4820.
Provider medical appeals
This type of appeal is available to providers with respect to a denial of services that have already been provided to the member and determined to be not medically necessary or appropriate. These appeals do not include member medical necessity appeals. Provider medical appeals should be submitted in writing to:
Dell Children’s Health Plan
Attn: Appeals
PO Box 37502 Oak Park, MI 48237-0502
FAX: 512-855-4909
Phone: 1-844-781-2343
Medical appeals can be initiated by the member or the provider on behalf of the member with the member’s signed consent. They must be submitted within 60 calendar days from receipt of an adverse determination for STAR and for CHIP, 180 days from the date of decision). Signed consent is not required for CHIP members. Be sure to include medical charts or other supporting information.
STAR medical appeals must be submitted in writing to:
Dell Children’s Health Plan
Medical Management- Appeals Team
1345 Philomena St. Suite 305
Austin, TX 78723
CHIP members may send a written request for appeal to the address above, or they can call member services at 1-855-921-6284 (TTY 711) to request an appeal.
Provider appeal process to Texas Health and Human Services Commission (HHSC) (related to claim recoupment due to member disenrollment)
A provider may appeal claim recoupment by submitting the following information to HHSC:
- A letter indicating that the appeal is related to a managed care disenrollment/recoupment and that the provider is requesting an exception request.
- The explanation of benefits (EOB) showing the original payment. Note: This is also used when issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an authorization for the exact items that were approved by the plan.
- The EOB showing the recoupment and/or the plan’s demand letter for recoupment. If sending the demand letter, it must identify the client name, identification number, date of service and recoupment amount. The information should match the payment EOB.
- Completed, clean claim. All paper claims must include both a valid NPI and TPI number. Note: In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted with the authorization number, and the provider will need to submit a corrected claim that contains the valid authorization number.
Mail HHSC recoupment appeal requests to the following address:
Texas Health and Human Services Commission
Claims Administrator Contract Management
Mail Code 91X
P.O. Box 204077
Austin, TX 78720-4077
