Member Complaints, Appeals, State Fair Hearing-Draft (pending HHSC approval)

How to file a Member Appeal for a Denied Service

You have 60 calendar days from the date of the denial letter to submit a request for an Appeal. If you want to keep getting services, you must file an appeal. You must file your appeal on or before 10 business days after we mail the letter or before the Services end. If a request for an appeal can be made verbally. An appeal request form will be mailed with the denial letter, and would like the form completed and returned. If your provider sends us the appeal, you or your representative will need to sign that request unless you need an emergency 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 1-877-324-7543 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 30 calendar 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 14 more days.

Request a Health Plan Appeal by either:

  • Filling out the “Health Plan Appeal Request Form” and mailing, emailing, or faxing it to:

Driscoll Health Plan Quality Management Department Attn: Member Appeals Team 4525 Ayers Street Corpus Christi, Texas 78415 Fax Number: 361-808-2186

  • Call Driscoll Health Plan at 1-877-324-7543; or
  • Emailing us at DHP_QM_Appeals@dchstx.org

Can someone from DHP help me file an appeal?

Yes. Contact Member Services at 1-877-324-7543 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 after the health plan’s internal appeal process has been completed. If you do not agree with our decision, you can ask for a State Fair Hearing with or without External Medical Review. You must make the request in writing for a State Fair Hearing with or without External Medical Review within 120 days of the date on the notice of action. If you do not ask for a State Fair Hearing with or without External Medical Review within 120 days, you may lose your right to a State Fair Hearing with or without External Medical Review. See facts below about how to ask for a State Fair Hearing.

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.

How can I ask for an Emergency Appeal?

Call Member Services to ask for an emergency appeal. The number is 1-877-324-7543. You can ask for an emergency 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 to you within one business day.

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

If DHP denies your request for an emergency 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 two calendar days.

Who can help me file an Emergency Appeal?

A Member Advocate will help you file an emergency appeal. If you need help, call Member Services at 1-877-324-7543.

External Medical Review

Can I ask for an External Medical Review?

If you disagree with the DHP internal appeal decision, you have the right to ask for an External Medical Review. An External Medical Review is an optional, extra step you can take to get the case reviewed for free before the State Fair Hearing occurs. You must request the External Medical Review with a State Fair Hearing, it cannot be requested alone. You may name someone to represent you by contacting the health plan and giving the name of the person you want to represent you, or completing the State Fair Hearing and External Medical Review Request Form. You or your representative must ask for an External Medical Review within 120 days of the date  DHP mails the letter with the internal appeal decision. If you do not ask for a State Fair Hearing with or without External Medical Review within 120 days, you may lose your right to an External Medical Review.

State Fair Hearing

Can I ask for a State Fair Hearing?

If you, as a Member of DHP, disagree with the health plan’s internal appeal decision, you have the right to ask for 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, or by completing the State Fair Hearing and External Medical Review Request Form. A doctor or other medical provider may be your representative. If you want to challenge a decision made by DHP, you or your representative must ask for the State Fair Hearing, with or without External Medical Review, within 120 days of the date on the letter DHP mails with the internal appeal decision. If you do not ask for the State Fair Hearing within 120 days, you may lose your right to a State Fair Hearing. To ask for a fair hearing, you or your representative should either call or send a letter to the health plan.

You have the right to keep getting any service DHP denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made. You must ask to continue your services within: (1) 10 calendar days from the date you get the health plan’s internal appeal decision letter or (2) the date services will change. If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most State Fair Hearings are held by phone. 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 with or without Emergency External Medical Review?

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 Driscoll Health Plan. You will need to complete DHP’s internal appeal process to request an Emergency State Fair Hearing, with or without Emergency External Medical Review.

Can I withdraw my request for an External Medical Review?

The Member or designated representative for 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 (IRO) 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. A decision will be mailed to you within 15 calendar days or less.

Requesting a State Fair Hearing or External Medical Review

If you ask for a State Fair Hearing, you can also ask for an External Medical Review where independent healthcare experts review your request to receive services. As we mentioned above, this review is an optional, extra step you can take to get your care reviewed for free before your State Fair Hearing. It doesn’t change your right to a State Fair Hearing. If you are happy with the decision from the External Medical Review, the Member or Authorized Representative can choose to withdraw the State Fair Hearing.

You may request a State Fair Hearing and External Medical Review by either:

  • Filling out the “State Fair Hearing and External Medical Review Request” Form attached to the appeal decision letter you received and mailing or faxing it to:

Driscoll Health Plan Utilization Management Department Attn: State Fair Hearing Coordinator 4525 Ayers Street Corpus Christi, Texas 78415 Fax Number: 844-407-5437

  • Calling Driscoll Health Plan at 1-877-324-7543;
  • Emailing us at DHPSFH@dchstx.org, or
  • Going in-person to a local HHSC Office.

To check on status of your State Fair Hearing or External Medical Review, call Member Services at 1-877-324-7543.

To learn more see the Appeal, External Medical Review, and State Fair Hearing section of your Member Handbook.