If you have a complaint about a service or care you received from Blue Cross and Blue Shield of Texas (BCBSTX) or one of our providers, please call a Customer Advocate at 1-877-688-1811 (TTY: 711). You can file a complaint by phone or ask for a complaint form to be mailed to you. Read the HHSC How to Submit a Complaint flyer to find out how to file a complaint.
You have the right to give written comments, documents, or other information for your complaint either by calling or in writing. BCBSTX will send you an acknowledgement letter within 5 business days of our receipt of your complaint telling you that we received it. If your complaint was received orally, the acknowledgement letter will include a complaint form. You can complete the complaint form and return it to us. You can include more information that will help us resolve your complaint.
While BCBSTX is looking into your problem, we will be getting facts from all the parties involved in your complaint. This might include providers, facilities, health plan staff or others. We will look at all of the facts. We will send you a letter with our decision within 30 calendar days of the day we get your complaint in writing. The decision letter will have the reasons why we made the decision.
You, your provider, or someone you trust can file a complaint with BCBSTX. You can write or call:
Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals Department
PO Box 660717
Dallas, TX 75266-0717
BCBSTX Customer Advocate Department: 1-877-688-1811 (TTY: 711)
Not happy with a decision that was made about your care? You can file an appeal.
You can file an appeal if:
- You are not getting a service you wanted.
- You did not get all the services approved that you asked for.
- You had a service approved before, but now it is ending.
- It is taking a long time to get the service you asked for.
Your appeal can be filed by your health care provider, friend, relative, lawyer or anyone else you choose. When you file an appeal, we will take another look at your case and see if there is something more we can do to help.
If you are not satisfied with the outcome of your complaint or appeal with BCBSTX, you can contact HHSC. You must finish the entire BCBSTX complaints and appeal process before you can file a complaint with HHSC Office of Ombudsman by either:
- Phone: 1-877-787-8999 or TTY 1-800-735-2989 or 7-1-1.
- Mail: Texas Health and Human Services Commission Office of the Ombudsman MC H-700P
P.O. Box 13247
Austin, TX 78711-3247 - Fax: 1-888-780-8099
How to File an Appeal
To request a health plan appeal you can:
- Fill out a Health Plan Appeal Request Form. Mail or fax it to us using the address or fax number listed at the top of the form.
- Call the BCBSTX Customer Advocate Department toll-free at 1-877-688-1811 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.
- Email to GPDTXMedicaidAG@bcbsnm.com.
- Call a Member Advocate for help filing an appeal at 1-877-375-9097 (TTY: 711).
You must request an appeal by 60 days from the date your notice for denial of services was mailed. We will give you a decision on your appeal within 30 days. You must request for your services to continue by 10 days from the date this notice is mailed, or the date services will change. You can make this request by phone. Call us at 1-877-688-1811 if you think this form will not reach us by mail before the deadline.
To request a pharmacy appeal you can:
- Call the BCBSTX Customer Advocate Department toll-free at 1-877-688-1811 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.
- Mail a written appeal to:
Blue Cross and Blue Shield of Texas
Attn: Prime Therapeutics Appeals Department
2900 Ames Crossing Road
Eagan, MN 55121
- Fax a written appeal to 1-855-212-8110.
- Have your doctor submit online at MyPrime.com or CoverMyMeds.com.
Emergency Health Plan or Pharmacy Appeal
If you feel your health will be seriously harmed by waiting for a decision on your health plan or pharmacy appeal, you or your doctor can ask for an emergency health plan or pharmacy appeal. If you qualify for an emergency health plan or pharmacy appeal, we must decide to approve or deny your appeal within 72 hours of your request.
State Fair Hearings and External Medical Reviews
If your appeal is denied, you have the right to ask for either a non-emergency or emergency State Fair Hearing or External Medical Review. A state fair hearing is when the Texas Health and Human Services Commission (HHSC) directly reviews our decisions with your medical care.
You or your representative must ask for the State Fair Hearing within 120 days of the date on the health plan’s letter 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 State Fair Hearing, you or your representative should either send a letter to the health plan at:
Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals Department
P.O. Box 660717
Dallas, Texas 75266-0717
Or call BCBSTX at 1-877-688-1811 (TTY: 711).
You have the right to keep getting any service the health plan denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made if you ask for a State Fair Hearing by the later of:
- ) 10 calendar days following the date the health plan mailed the internal appeal decision letter, or
- ) the day the health plan’s internal appeal decision letter says your service will be reduced or end.
If you do not request a State Fair Hearing by this date, the service the health plan denied will be stopped. 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 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.
If you ask for a State Fair Hearing, you can also ask for an External Medical Review where independent health care experts review your request to receive services. The External Medical Review is an optional, extra step you can take to get your case reviewed for free before your State Fair Hearing. It doesn’t change your right to a State Fair Hearing.
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 and mail or fax it to BCBSTX by using the address or fax number below:
Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals Department
P.O. Box 660717
Dallas, Texas 75266-0717
Fax to 1-855-235-1055 - Call BCBSTX at 1-877-688-1811 (TTY: 711) or email us at GPDTXMedicaidAG@bcbsnm.com if you have questions.
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. If you have questions, please call the BCBSTX Customer Advocate Department toll-free 1-877-688-1811 (TTY: 711) or the 24-Hour Nurse Advice Line at 1-844-971-8906. 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 the BCBSTX at 1-877-688-1811 (TTY: 711) or emailing 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.
Find out more about filing complaints, appeals, emergency appeals, state fair hearings and external medical reviews by calling one of the following numbers:
- BCBSTX Customer Advocate Department: 1-877-688-1811 (TTY: 711)
- STAR Kids Member Advocate in the Central Service Delivery Area: 1-855-497-0857 (TTY: 711).
- STAR Kids Member Advocate in the Travis Service Area:] (TTY: 711)
For more information regarding Complaints, Appeals and the State Fair Hearing, please refer to Your Rights for an Appeal of an Adverse Determination and the Complaints and Appeals section of your Member Handbook.