Cómo funciona su plan

Una vez que envíe su solicitud a la Comisión de Salud y Servicios Humanos (HHSC), la procesarán y le dirán si usted califica para CHIP o (STAR) Medicaid para niños.

Asegúrese de elegir un proveedor de cuidado primario (PCP) que acepte CHIP/STAR Medicaid del Dell Children’s Health Plan. Haga clic en Buscar un médico o haga clic aquí para ver el Directorio de proveedores de CHIP, el Directorio de proveedores perinatales de CHIP o el Directorio de proveedores de STAR. Llame a Servicios para miembros al 1-855-921-6284 para que le envíen por correo un directorio de proveedores sin ningún costo para usted.

Siempre debe poder comunicarse con su PCP, 24/7, llamando al número del consultorio de su médico. Si el consultorio está cerrado, es posible que se le envíe a un servicio de contestador. Ellos sabrán cómo comunicarse con el médico o le pedirán que deje un teléfono para que el médico pueda devolverle la llamada. El Dell Children’s Health Plan también ofrece una línea directa de enfermería las 24 horas del día. Puede llamar al 1-855-712-6700.

Recuerde que puede cambiar a su PCP en cualquier momento. Llame a Servicios para miembros de Dell Children’s Health Plan al 1-855-921-6284 para hacer el cambio. Servicios para miembros puede decirle cuándo puede ir a su nuevo PCP.

Quizás no pueda cambiar su PCP si:

  • El PCP nuevo no está en la red de Dell Children’s Health Plan o
  • El PCP nuevo no acepta pacientes nuevos

Remisión con especialistas

Algunas veces, su proveedor de atención primaria necesitará que usted consulte a un especialista o a otro proveedor para que le preste los servicios o la atención médica que no puede prestar. A esto se le llama “remisión”. Su médico también puede necesitar que aprobemos ciertos servicios antes de que usted los reciba. A esto se le llama “aprobación previa”.

A partir del 1 de abril de 2014, las remisiones suyas o del PCP de su hijo ya no serán necesarias para los miembros de CHIP o STAR de Dell Children’s Health Plan.

Puede obtener servicios de obstetricia/ginecología (OB/GYN), planificación familiar y servicios de salud conductual sin una remisión de su médico. A esto se le llama “autorremisión”. Para obtener servicios, haga una cita con un médico de nuestra red. Puede encontrar una lista de médicos utilizando la herramienta de búsqueda Buscar un médico o un proveedor de salud conductual utilizando esta herramienta.


También podemos proveer un manual para miembros en:

  • Audio
  • Letra grande
  • Braille
  • Un idioma distinto al inglés o español


Comuníquese con Servicios para miembros al 1-855-921-6284 (TTY 7-1-1).

Tanto la cobertura de CHIP como la de STAR duran un año. Cerca del final de la cobertura, recibirá una solicitud de renovación. Complétela y devuélvala lo más pronto posible. La HHSC tramitará su solicitud de renovación. Si tiene problemas, también estamos aquí para ayudarlo en todo el proceso de renovación. Llámenos al 1-855-921-6284.

Tanto la cobertura de CHIP como la de STAR duran un año.

CHIP Member rights
  • You have the right to get accurate, easy-to-understand information to help you make good choices about your child’s health plan, doctors, hospitals and other providers.
  • Your health plan must tell you if they use a “limited provider network.” This is a group of doctors and other providers who only refer patients to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses “limited networks,” you should check to see that your child’s primary care provider and any specialist doctor you might like to see are part of the same “limited network.”
  • You have a right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know about what those payments are and how they work.
  • You have a right to know how the health plan decides whether a service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.
  • You have a right to know the names of the hospitals and other providers in your health plan and their addresses.
  • You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it.
  • If a doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child’s primary care provider. Ask your health plan about this.
  • Children who are diagnosed with special health care needs or a disability have the right to special care.
  • If your child has special medical problems, and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months and the health plan must continue paying for those services. Ask your plan about how this works.
  • Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her primary care provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral.
  • Your child has the right to emergency services if you reasonably believe your child’s life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a co-payment depending on your income.
  • You have the right and responsibility to take part in all the choices about your child’s health care.
  • You have the right to speak for your child in all treatment choices.
  • You have the right to get a second opinion from another doctor in your health plan about what kind of treatment your child needs.
  • You have the right to be treated fairly by your health plan, doctors, hospitals and other providers.
  • You have the right to talk to your child’s doctors and other providers in private, and to have your child’s medical records kept private. You have the right to look over and copy your child’s medical records and to ask for changes to those records.
  • You have the right to a fair and quick process for solving problems with your health plan and the plan’s doctors, hospitals and others who provide services to your child. If your health plan says it will not pay for a covered service or benefit that your child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.
  • You have a right to know that doctors, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even it the care or treatment is not a covered service.
CHIP Member responsibilities
  • You and your health plan both have an interest in seeing your child’s health improve. You can help by assuming these responsibilities.
  • You must try to follow healthy habits, such as, encourage your child to exercise, to stay away from tobacco, and to eat a healthy diet.
  • You must become involved in the doctor’s decisions about your child’s treatments.
  • You must work together with your health plan’s doctors and other providers to pick treatments for your child that you have all agreed upon.
  • If you have a disagreement with your health plan, you must try first to resolve it using the health plan’s complaint process.
  • You must learn about what your health plan does and does not cover. Read your Member Handbook to understand how the rules work.
  • If you make an appointment for your child, you must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and cancel it.
  • If your child has CHIP, you are responsible for paying your doctor and other providers co-payments that you owe them. If your child is getting CHIP Perinatal Program services, you will not have any, co-payments for that child.
  • You must report misuse of CHIP or CHIP Perinatal Program services by health care providers, other members, or health plans.
  • If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and


Human Services (HHS) toll-free at 800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

CHIP Perinatal Member rights
  • You have a right to get accurate, easy-to-understand information to help you make good choices about your unborn child’s health plan, doctors, hospitals, and other providers.
  • You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work.
  • You have a right to know how the health plan decides whether a Perinatal service is covered or medically necessary. You have the right to know about the people in the health plan who decide those things.
  • You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses.
  • You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed.
  • You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan.
  • You have the right and responsibility to take part in all the choices about your unborn child’s health care.
  • You have the right to speak for your unborn child in all treatment choices.
  • You have the right to be treated fairly by the health plan, doctors, hospitals, and other providers.
  • You have the right to talk to your Perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records.
  • You have the right to a fair and quick process for solving problems with the health plan and the plan’s doctors, hospitals and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.
  • You have a right to know that doctors, hospitals, and other Perinatal providers can give you information about your or your unborn child’s health status, medical care, or treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
CHIP Perinatal Member responsibilities

You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities:

  • You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet.
  • You must become involved in the decisions about your unborn child’s care.
  • If you have a disagreement with the health plan, you must try first to resolve it using the health plan’s complaint process.
  • You must learn about what your health plan does and does not cover. Read your CHIP Perinatal Program Handbook to understand how the rules work.
  • You must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and cancel it.
  • You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans.
  • You must talk to your provider about your medications that are prescribed.
  • You must talk to your provider about your medications that are prescribed.
  • If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights
STAR Member rights
  1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:
    • Be treated fairly and with respect.
    • Know that your medical records and discussions with your providers will be kept private and confidential.
  2. You have the right to a reasonable opportunity to choose a health-care plan and primary care provider. This is the doctor or health-care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to:
    • Be told how to choose and change your health plan and your primary care provider.
    • Choose any health plan you want that is available in your area and choose your primary care provider from that plan.
    • Change your primary care provider.
    • Change your health plan without penalty.
    • Be told how to change your health plan or your primary care provider.
  3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to:
    • Have your provider explain your health-care needs to you and talk to you about the different ways your health-care problems can be treated.
    • Be told why care or health-care services were denied and not given.
  4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:
    • Work as part of a team with your provider in deciding what health care is best for you.
    • Say yes or no to the care recommended by your provider.
  5. You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid and get a timely response to complaints, appeals, and state fair hearings. That includes the right to:
    • Make a complaint to your health plan or to the state Medicaid program about your health care, your provider, or your health plan.
    • Get a timely answer to your complaint.
    • Use the plan’s appeal process and be told how to use it.
    • Ask for a state fair hearing from the state Medicaid program and get information about how that process works.
  6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to:
    • Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need.
    • Get medical care in a timely manner.
    • Be able to get in and out of a health-care provider’s office; this includes barrier-free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act.
    • Have interpreters, if needed, during appointments with your providers and when talking to your health plan; interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information.
    • Be given information you can understand about your health plan rules, including the health-care services you can get and how to get them.
  7. You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you.
  8. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.
  9. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.
STAR Member responsibilities
  1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to:
    • Learn and understand your rights under the Medicaid program.
    • Ask questions if you do not understand your rights.
    • Learn what choices of health plans are available in your area.
  2. You must abide by the health plan and Medicaid’s policies and procedures. That includes the responsibility to:
    • Learn and follow your health plan’s rules and Medicaid rules.
    • Choose your health plan and a primary care provider quickly.
    • Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan.
    • Keep your scheduled appointments.
    • Cancel appointments in advance when you cannot keep them.
    • Always contact your primary care provider first for your non-emergency medical needs.
    • Understand when you should and should not go to the emergency room.
  3. You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to:
    • Tell your primary care provider about your health.
    • Talk to your providers about your health-care needs and ask questions about the different ways your health-care problems can be treated.
    • Help your providers get your medical records.
  4. You must be involved in decisions relating to service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to:
    • Work as a team with your provider in deciding what health care is best for you.
    • Understand how the things you do can affect your health.
    • Do the best you can to stay healthy.
    • Treat providers and staff with respect.
    • Talk to your provider about all your medications.

Additional member responsibilities while using Nonemergency Medical Transportation (NEMT) services:

  1. When requesting NEMT services, you must provide the information requested by the person arranging or verifying your transportation.
  2. You must follow all rules and regulations affecting your NEMT services.
  3. You must return unused advanced funds; you must provide proof that you kept your medical appointment prior to receiving future advanced funds.
  4. You must not verbally, sexually, or physically abuse or harass anyone while requesting or receiving NEMT
  5. You must not lose bus tickets or tokens and must return any bus tickets or tokens that you do not use; you must use the bus tickets or tokens only to go to your medical appointment.
  6. You must only use NEMT services to travel to and from your medical appointments.
  7. If you have arranged for an NEMT service but something changes, and you no longer need the service, you must contact the person who helped you arrange your transportation as soon as possible.


If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

Advance directives

An Advance Directive helps you make choices about your health care ahead of time. It can explain your wishes if you’re ever unable to speak or make health choices for yourself. It also says who will make choices for you if you cannot. Your doctor should talk about Advance Directives with you. It’s a good idea to give a copy of your directive to the doctor, the person acting for you and a family member. Take a copy with you when you go to the doctor or hospital.

Quejas

What should I do if I have a complaint? Who do I call?

We want to help. If you have a complaint, please call Member Services at 1-855-921-6284 (TTY 7-1-1) to tell us about your problem.

Can someone from Dell Children’s Health Plan help me file a complaint?

Yes. A Dell Children’s Health Plan Member Advocate can help you file a complaint with Dell Children’s Health Plan or with the appropriate state program. Just call 1-855-921-6284 (TTY 7-1-1) and ask to talk to a Dell Children’s Health Plan member advocate. Most of the time, we can help you right away or at the most within a few days. You can also send a letter to Dell Children’s Health Plan to tell us about your problem.

Send the letter to:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723.

How long will it take to process my complaint?

Dell Children’s Health Plan will send you a letter within 5 business days of receiving your complaint. We will then look into the issue. We will resolve the complaint within 30 days of receiving it, and notify you by mail.

What are the requirements and timeframes for filing a complaint?

You can file a complaint at any time. You do not have to wait to file a complaint.

Who do I call for process or status questions?

You may contact Member Services at 1-855-921-6284 (TTY 7-1-1) for any questions about the process or the status of your complaints and/or appeals.

If I am not satisfied with the outcome of my complaint, can I file an appeal?

Once you have gone through the Dell Children’s Health Plan complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989.

If you would like to make your Complaint in writing, please send it to the following address:  

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247

If you can get on the Internet, you can submit your complaint at:

hhs.texas.gov/managed-care-help

If you do not feel Dell Children’s Health Plan gave you the right answer for your complaint, you can appeal the decision. Call Member Services at 1-855-921-6284 (TTY 7-1-1) and they can help you file an appeal. If you receive benefits through Medicaid’s STAR program, call your health 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
  • 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)

Proceso de apelación STAR Medicaid

What can I do if my doctor asks for a service for me that’s covered but Dell Children’s Health Plan denies or limits it?

There may be times when Dell Children’s Health Plan says it will not pay for or cover all or part of the care that has been recommended. You have the right to ask for an appeal. An appeal is when you or your designated representative asks Dell Children’s Health Plan to look again at the care your doctor asked for and we said we will not pay for.

You can appeal our decision in 2 ways:

  1. You can call Member Services at 1-855-921-6284
  2. You can send us a letter to:
    Dell Children’s Health Plan Appeals
    1345 Philomena St., Ste 305
    Austin, TX 78723.
How will I find out if services are denied?

If we deny coverage, we will send you a letter.

What are the time frames for the appeals process?

You or a designated representative can file an appeal. You must do this within 60 days of the date of the first letter from Dell Children’s Health Plan that says we will not pay for or cover all or part of the care that has been recommended.

When we get your letter or call, we will send you a letter within 5 business days. This letter will let you know we got your appeal. We will also let you know if we need any other information to process your appeal. Dell Children’s Health Plan will contact your doctor if we need medical information about this service.

If you ask someone (a designated representative) to file an appeal for you, you must also send a letter to Dell Children’s Health Plan to let us know you have chosen a person to represent you.

Dell Children’s Health Plan must have this written letter to be able to consider this person as your representative. We do this for your privacy and security.

A doctor who has not seen your case before will look at your appeal. He or she will decide how we should handle your appeal. We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal unless we need more information from you or the person you asked to file the appeal for you. If we need more information, we may extend the appeals process for 14 days. If we extend the appeals process, we will let you know the reason for the delay. You may also ask us to extend the process if you know more information that we should consider.

How can I continue receiving my services that were already approved?

To continue receiving services that have already been approved by Dell Children’s Health Plan but may be part of the reason for your appeal, you must file the appeal on or before the later of:

  • 10 business days after we mail the notice to you to let you know we will not pay for or cover all or part of the care that has already been approved
  • The date the notice says your service will end

If you request that services continue while your appeal is pending, you need to know that you may have to pay for these services.

If the decision on your appeal upholds our first decision, you may be asked to pay for the services you received during the appeals process.

If the decision on your appeal reverses our first decision, Dell Children’s Health Plan will pay for the services you received while your appeal was pending.

Can someone from Dell Children’s Health Plan help me file an appeal?

Yes, a member advocate or Member Services representative can help you file an appeal.

Please call Member Services toll-free at 1-855-921-6284 (TTY 7-1-1).

Can members request a state fair hearing with or without external medical review?

Yes, you can ask for a fair hearing after the Dell Children’s Health Plan appeal process. See the state fair hearings section below for more information.

Who do I call for process or status questions?

You may contact your member services representative at 1-855-921-6284 (TTY 7-1-1) for any questions about the process or the status of your complaints and/or appeals.

Solicitudes de audiencia estatal y de revisión médica externa

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. 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 appeal 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 or a State Fair Hearing and External Medical Review Request form to the health plan at:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723.

Or you can call Member Services at 1-855-921-6284 (TTY 7-1-1). We can help you with this request.

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:

  • 10 calendar days following the Dell Children’s Health Plan mailing of the notice of the action or
  • 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 I ask for an emergency State Fair Hearing?

If you believe that waiting for a State Fair Hearing will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you or your representative may ask for an emergency State Fair Hearing by writing or calling Dell Children’s Health Plan. To qualify for an emergency State Fair Hearing through HHSC, you must first complete Dell Children’s Health Plan’s internal appeals process.

Can I ask for an external medical review?

If a member, as a member of the health plan, disagrees with the health plan’s internal appeal decision, the member has the right to ask for an external medical review. An external medical review is an optional extra step the member can take to get the case reviewed before the state fair hearing occurs. The member may name someone to represent them by contacting the health plan and giving the name of the person the member wants to represent him or her. A provider may be the member’s representative. The member or the member’s representative must ask for the external medical review within 120 days of the date the health plan mails the letter with the internal appeal decision. If the member does not ask for the external medical review within 120 days, the member may lose his or her right to an external medical review. To ask for an external medical review, the member or the member’s representative may either:

  • Fill out the State Fair Hearing and External Medical Review Request Form (link to come) and mail or fax it to Dell Children’s Health Plan by using the address or fax number at the top of the form;
  • Call Dell Children’s Health Plan at 512-324-3013 or 1-855-962-4453 (TTY 7-1-1); or
  • Email Dell Children’s Health Plan at dchp-UM@ascension.org

If the member asks for an external medical review within 10 days from the time the member gets the appeal decision from the health plan, the member has the right to keep getting any service the health plan denied, based on previously authorized services, at least until the final state fair hearing decision is made. If the member does not request an external medical review within 10 days from the time the member gets the appeal decision from the health plan, the service the health plan denied will be stopped.

The member may withdraw the member’s request for an external medical review before it is assigned to an independent review organization or while the independent review organization is reviewing the member’s external medical review request. An independent review organization is a third-party organization contracted by HHSC that conducts an external medical review during member appeal processes related to adverse benefit determinations based on functional necessity or medical necessity. An external medical review cannot be withdrawn if an independent review organization has already completed the review and made a decision.

Once the external medical review decision is received, the member has the right to withdraw the state fair hearing request. If the member continues with the state fair hearing, the member can also request the independent review organization be present at the state fair hearing. The member can make both of these requests by contacting Dell Children’s Health Plan or the HHSC Intake Team at EMR_Intake_Team@hhsc.state.tx.us.

If the member continues with a state fair hearing and the state fair hearing decision is different from the independent review organization decision, it is the state fair hearing decision that is final. The state fair hearing decision can only uphold or increase member benefits from the independent review organization decision

If you have any questions during the process, please call Member Services at 1-855-921-6284 (TTY 7-1-1).

Can I ask for an emergency external medical review?

If you believe that waiting for a standard external medical review will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you, your parent or your legally authorized representative may ask for an emergency external medical review and emergency State Fair Hearing by writing or calling Dell Children’s Health Plan.

Procedimiento de reclamación CHIP

Por queja se entiende cualquier insatisfacción que nos exprese verbalmente o por escrito sobre cualquier aspecto de nuestro funcionamiento, incluidos, entre otros, la insatisfacción con la administración del plan; los procedimientos relacionados con la revisión o apelación de una determinación adversa; la denegación, reducción o finalización de un servicio por motivos no relacionados con la necesidad médica; la forma en que se presta un servicio; o las decisiones de desafiliación.

Filing a complaint

If you are not satisfied with the way we handled the request for services for your child or your appeal, you, your provider, or someone acting on your behalf can file a complaint against Dell Children’s Health Plan. A complaint about our decision not to pay for a service your child needs is considered an appeal and will follow the appeal process outlined above. 

To file a complaint, call us at 1-855-921-6284 (TTY 7-1-1). You can also send us a letter telling us about your complaint. Send the letter to: 

Member Advocate
Dell Children’s Health Plan 
1345 Philomena St., St. 305
Austin, TX 78723

In your letter or call, tell us why you are dissatisfied with the way we handled the request for services for your child or our appeals process. You can tell us what you’re unhappy with such as:

  • The way we served or treated you
  • The way the appeals process works
  • How long it took us to make a decision


We’ll send you a letter telling you we got your complaint within 5 business days from the date of your complaint.

We’ll look into your complaint and mail our answer to you no later than 30 calendar days from the date we received your written complaint or completed Member Complaint Form. Our letter will also tell you how we resolved your complaint. 

If your complaint is for an emergency or denial of continued stay for hospitalization, it will be resolved:

  • According to the medical or dental urgency of your case.
  • No later than 1 business day from the date we receive your complaint.
Filing a complaint with the Texas Department of Insurance

You, your provider, or a person acting on your behalf can file a complaint with the Texas Department of Insurance at any time. To file a complaint, you can: 

  • Call 1-800-252-3439.
  • Send a letter to:
    Texas Department of Insurance
    Consumer Protection Section
    Mail Code 111-1A
    PO Box 149091
    Austin, TX 78714-9091
  • Follow the instructions online at tdi.texas.gov/consumer/complfrm.html.
How to get a copy of our records of your complaint

You can get a copy of our records about your complaint and any related proceeding. Call us at 1-855-921-6284 (TTY 7-1-1) to request a copy.

How can I know my complaint was received?

If you notify us orally or in writing of a complaint, we will, not later than the 5th business day after the date of the receipt of the complaint, send to you a letter acknowledging the date we received your complaint.

We will investigate and send you a letter with our resolution. The total time for acknowledging, investigating, and resolving your complaint will not exceed 30 calendar days after the date we receive your complaint.

Your complaint concerning an emergency or denial of continued stay for hospitalization will be resolved in 1 business day of receipt of your complaint. The investigation and resolution shall be concluded in accordance with the medical immediacy of the case.

You may use the appeals process to resolve a dispute regarding the resolution of your complaint.

Once you have gone through the Dell Children’s Health Plan complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989. If you would like to make your Complaint in writing, please send it to the following address:

Texas Health and Human Services Commission
Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, Texas 78711-3247

If you can get on the Internet, you can submit your complaint at hhs.texas.gov/managed-care-help.

Proceso de apelación de CHIP

What can I do if my child’s provider asks for a service for my child that is covered but Dell Children’s Health Plan denies or limits it?

There may be times when Dell Children’s Health Plan says it will not pay for care that has been recommended by your provider. If we do this, you, the person acting on your behalf or your child’s provider can appeal the decision. An appeal is when you ask Dell Children’s Health Plan to look again at the care your child’s provider asked for and we said we will not pay for. You must file for an appeal within 30 days from the date on our first letter that says we will not pay for a service.

How will I find out if services are denied?

You will receive a letter if you have services that are denied.

What are the time frames for the appeal process?

When we get your letter or call, we will send you a letter within 5 business days. This letter will let you know we got your appeal. A doctor who has not seen your case before will look at your appeal. He or she will decide how we should handle your appeal.

We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal. We have a process to answer your appeal quickly if the care your provider says your child needs is urgent.

If you are not happy with the answer to your first level appeal, you can ask your child’s doctor to ask us to look at the appeal again. This is called a second level appeal. Your child’s provider must send us a letter to ask for a second level appeal within 10 business days of the date on the first level appeal letter from Dell Children’s Health Plan.

When we get the letter asking for the appeal, we will send you a letter within 5 business days. This letter will let you know we got the letter asking for a second level appeal. A provider who specializes in the type of care your child’s provider asked for will look at your case. We’ll tell you our decision within 15 business days from when we receive the specialty review appeal request from your child’s provider. This letter is our final decision. If you do not agree with our decision you may request an independent review form by calling 1-855-921-6284. We will send you a form to fill out.

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

You must request an appeal within 60 days from the date on the first letter from Dell Children’s Health Plan that says we will not pay for the service. If you, the person acting on your behalf, or the provider are not happy with the answer to your first level appeal, the provider must 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.

If you file an appeal, Dell Children’s Health Plan will not hold it against you. We will still be here to help you get quality health care.

Where can I send written requests?

You can mail any written requests to:

Dell Children’s Health Plan Appeals
1345 Philomena St., Ste 305
Austin, TX 78723

Does my request have to be in writing?

No. You can request an appeal by calling Member Services at 1-855-921-6284 (TTY 7-1-1).

Can someone from Dell Children’s Health Plan help me file an appeal?

You can call Member Services at 1-855-921-6284 (TTY 7-1-1) if you need help filing an appeal. If you file a medical appeal, Dell Children’s Health Plan will not hold it against you. We will still be here to help you get quality health care.

Who Do I call for process or status questions?

You may contact member services at 1-855-921-6284 (TTY 7-1-1) for any questions about the process or the status of your complaints and/or appeals.

What is an emergency appeal?

An emergency 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. 

Si pierde su tarjeta de identificación del Dell Children’s Health Plan, se la roban o es incorrecta, llame a Servicios al Miembro al 1-855-921-6284.

Le enviaremos uno de sustitución.

También puede ver o imprimir su tarjeta de identificación de miembro actual del Dell Children’s Health Plan en el portal de miembros.

Dependiendo de su plan, su tarjeta de identificación tendrá este aspecto:

Example of a STAR Member ID Card

Dell Children’s Health Plan está aquí para ayudarlo.

Las tarjetas de identificación del Dell Children’s Health Plan se verán diferentes para los miembros de CHIP y CHIP Perinate. Esto es sólo un ejemplo.

CHIP y STAR Medicaid pagan la mayoría de los medicamentos que le recete su médico. Tanto los adultos como los niños pueden obtener tantas recetas como sean médicamente necesarias. Puede surtir su receta en cualquier farmacia de nuestro plan, a menos que esté en el programa Medicaid Lock-in.

Su hijo puede obtener tantas recetas como sean médicamente necesarias. Utilizamos la lista de medicamentos del Vendor Drug Program (VDP) para que su médico pueda elegir. Algunas recetas pueden tener un copago. Para más información sobre los copagos, consulte la sección «¿Qué son los copagos?» de su manual del afiliado si es afiliado de CHIP.

Algunas recetas necesitan autorización previa. Puede acudir a cualquier farmacia de nuestro plan para que le surtan sus recetas. Para más información, llame a Servicios para Miembros al 1-855-921-6284 (TTY 7-1-1).

Centros que atienden después de horas laborales

También puede ver una lista de centros de atención de urgencia y de centros que atienden después de horas laborales aquí.

Centros de atención de urgencia

También puede ver una lista de centros de atención de urgencia y de centros que atienden después de horas laborales aquí.