How to Appeal (STAR Members & STAR Kids)

How to Appeal a Denied Service

You have 60 calendar days from the date on this letter to submit a request for an Appeal. If we are denying services that you currently receiving, you must file an appeal within ten (10) days of the denial letter or within ten (10) days of the date the denial will take place. If a request for an appeal is received verbally, you/your provider will need to put the appeal in writing. If your provider sends us the appeal, you or your representative will need to sign that request unless you need an expedited appeal. For facts about how to file this appeal using the form that was sent to you or to check on the status of the appeal, call Member Services toll-free at 1-877-DCHP-KIDS (324-7543) for help filing an appeal.

We will send you a letter within five (5) days of receiving your appeal, to let you know that we did receive it. We will complete the appeal review within thirty (30) days. If we need more time to review the appeal, we will send you a letter telling you why we need more time. You can also ask for more time to resolve the appeal. Your appeal can be extended up to fourteen (14) more days.

You may send request for appeal to:
Driscoll Health Plan
Attn: Clinical Appeals Department
615 N Upper Broadway, Suite 1621
Corpus Christi, Texas 78401-0764
Fax: 361-881-1349

Can I appeal when Driscoll Health Plan (DHP) has not paid a claim?

Yes, you can submit an appeal in writing. Call Member Services at 1-877-DCHP-KIDS (324-7543) for help filing an appeal.

Can someone from DHP help me file an appeal?

Yes. Contact Member Services at 1-877-DCHP-KIDS (324-7543) for help filing an appeal.

Can I file an appeal with the Health and Human Services Commission?

You have the right to appeal to the state at any time during or after the plan’s appeal process. If you do not agree with our decision, you can ask for a State Fair Hearing. You must make the request in writing for a Fair Hearing within ninety (90) days of the date on the notice of action. If you do not ask a hearing within 90 days, you lose your right to a hearing. See facts below about how to ask for a State Fair Hearing.

Expedited Appeal

What is an Expedited Appeal?

An expedited 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.

How can I ask for an Expedited Appeal?

Call Member Services to ask for an expedited appeal. The number is 1-877-DCHP-KIDS (324-7543). You can ask for an expedited appeal verbally, or in writing. Member Services will arrange for a Member Advocate to help you. We will review your case and get back to you within three business days after we receive your request. If the request is an emergency or for when you are in the hospital we will get back with you within one business day.

What happens if the health plan denies the request for an expedited appeal?

If DHP denies your request for an expedited appeal, we will refer your appeal to the regular appeal process, and call you to inform you of the denial right away. We will then follow up with a letter within 2 calendar days.

Who can help me file an Expedited Appeal?

A Member Advocate will help you file an expedited appeal. If you need help, call Member Services at 1-877-DCHP-KIDS (324-7543).

State Fair Hearing

Can I ask for a State Fair Hearing?

If you, as a Member of DHP, disagree with the health plan’s decision, you have the right to ask for a fair hearing.You must complete Driscoll Health Plan’s internal appeal process before requesting a state fair hearing.You may name someone to represent you by writing a letter to DHP 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 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 to the health plan at:

Driscoll Health Plan
615 N Upper Broadway, Suite 1621
Corpus Christi, Texas 78401-0764

To check on status of State Fair Hearing call Member Services at 1-877-DCHP-KIDS (324-7543).

You have the right to keep getting any service DHP denied or reduced at least until the final hearing decision is made if you ask for a fair hearing by the later of: (1) 10 days from the date you get the health plan’s decision letter or (2) the day the health plan’s letter says you service will be reduced or end. If you do not ask for a fair hearing by this date, the service DHP 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.