Complaints and Appeals
Complaints and 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 or through your assigned Provider Relations Liaison. You may also file complaints by fax at 512-855-4909, through email at DCHPComplaints@ascension.org, or by mail by using the address below:
Dell Children’s Health Plan
Attn: Complaints
PO Box 37502
Oak Park, MI 48237-0502
If your complaint cannot be resolved within one business day, Dell Children’s Health Plan will send you an acknowledgement complaint letter within five business days of getting your complaint. Please be advised that a resolution letter will be mailed to you within 30 calendar days from the date we received your complaint. This letter will include all the detailed information about the actions taken to address the concerns you’ve raised.
After completing the complaint process with Dell Children’s Health Plan, if you are not satisfied with the resolution, you can submit a written complaint with the Health and Human Services Commission, using the following email address: HPM_Complaints@hhsc.state.tx.us.
Or by mail:
Texas Health and Human Services Commission
Medicaid/CHIP
Health Plan Management
Mail Code H-320
P.O. Box 85200
4900 N. Lamar
Austin, TX 78708-5200
Provider claim payment reconsideration, appeals and overpayment disputes
The information below is a summary of each process. For full details, refer to Dell Children’s Health Plan’s provider manual or provider portal.
If you have more questions about the reconsideration, appeals or dispute process, you may reach out to our Provider Services line by calling us at 1-844-781-2343 or you may email your Provider Relations Liaison at shpproviderservices@seton.org.
Provider claim payment reconsideration and appeal process
If you disagree with the outcome of a claim, you may use the Dell Children’s Health Plan provider claim payment resolution process. The simplest way to define a claim payment dispute is any claim payment disagreement between the health care provider and Dell Children’s Health Plan.
The Dell Children’s Health Plan provider claim payment resolution process consists of two internal options:
- Level 1 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.
- Level 2 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 reconsiderations
The first available option in the Dell Children’s Health Plan claim payment dispute process is a level one reconsideration. The reconsideration 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.
How to submit your reconsideration:
- Online through our Provider Portal on the Dell Children’s Health Plan website.
- In 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.
- Call Dell Children’s Health Plan Provider Services at 1-844-781-2343 (for reconsiderations only)
- Mail (for reconsiderations and claim payment appeals) all required documentation, including the Provider Payment Dispute and Correspondence Submission Form to:
Payment Dispute Unit
Dell Children’s Health Plan
PO Box 37502
Oak Park MI 48237-0502
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
If you are dissatisfied with the outcome of a reconsideration determination or wish to bypass the reconsideration process altogether, you may submit a level two claim payment appeal. Dell Children’s Health Plan accepts claim payment appeals online through the Provider Portal on the Dell Children’s Health Plan website or in writing within the latter of:
- 30 calendar days from the date on the reconsideration determination letter, or
- 120 calendar days from the date of the original EOP
Mail (for reconsiderations and claim payment appeals) all required documentation, including the Provider Payment Dispute and Correspondence Submission Form to:
Payment Dispute Unit
Dell Children’s Health Plan
PO Box 37502,
Oak Park MI 48237-0502
Claim payment appeals received later than these timeframes will be considered untimely and upheld unless good cause can be established. Dell Children’s Health Plan will resolve the claim payment appeal within 30 calendar days of receipt.
How to submit a claim overpayment dispute
Providers may appeal an overpayment request from DCHP like any other claims appeal and with the same process outlined in the Provider Manual.
If you have questions about an overpayment letter you recently received, you may reach out to our provider services team at 1-844-781-2343 to assist with your questions. Calling provider services is not a formal claim overpayment dispute.
To file a claim overpayment dispute, you may submit:
- Online through the Provider Portal on the Dell Children’s Health Plan website.
- In the provider portal, you can upload supporting documentation and will receive immediate acknowledgement of your dispute. You may select the type of dispute as an overpayment dispute.
- 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 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
Provider appeal process to TDI (for CHIP members)
If a CHIP member or the member’s representative is not satisfied with the outcome of Dell Children’s Health Plan’s appeal process, they can file a complaint with the Texas Department of Insurance (TDI). The member can contact TDI by calling toll free 1-800-252-3439 or in writing to:
Consumer Protection, Mail Code 111-1A
Texas Department of Insurance
P.O. Box 149091
Austin, TX 78714-9091
The CHIP member can also submit their complaint online at tdi.texas.gov/consumer/get-help-with-an-insurance-complaint.html.
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.
