STAR/Medicaid Member Complaint and Appeals Process

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1 STAR/Medicaid Member Complaint and Appeals Process What should I do if I have a complaint? We want to help. If you have a complaint, please call us toll-free at to tell us about your problem. A Sendero Health Plans Member Services Advocate can help you file a complaint. Just call Most of the time, we can help you right away or at the most within a few days. Once you have gone through the Sendero s complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free If you would like to make your complaint in writing, please send it to the following address: Texas Health and Human Services Commission Health Plan Operations - H-320 P.O. Box Austin, TX ATTN: Resolution Services If you can get on the Internet, you can send your complaint in an to We will send you a letter to let you know we received the complaint. This letter will be sent within five (5) days of receiving your complaint. We will send you a form to complete and mail to us. We will not follow-up on your complaint unless you put it in writing. We will not punish you for filing a complaint. Your doctor may file a complaint for you. We will not punish you or your doctor for filing a complaint. Most of the time, we can help you right away or at the most within a few days. At the most, we will respond with an answer to your complaint within thirty (30) days of receipt. If you are not happy with the way we help you, you can call us and appeal. Sendero wants to help you get the best healthcare for your family. If you have questions about how to file a complaint, an appeal, or need additional help, call us toll-free at We will be glad to help. Call us: Sendero Health Plans Member Services Write to us: Sendero Health Plans ATTN: Member Advocate 2028 East Ben White Blvd. Suite 510

2 All complaints are reviewed to make sure that there is follow-up. They are also reviewed to make sure that timely answers are given. A You also have the right to meet with a Complaints Appeal Panel. This panel is made up of doctors and others who will hear your complaint and make a decision. Who do I call? Please call Sendero s Customer Services toll-free at Can someone from Sendero help me file a Complaint? Yes, either one of Sendero s Customer Service agents can help you or the Quality Improvement Manager can help you file a complaint. How long will it take to process my Complaint? Sendero send you a letter telling you about our decision. You will receive this letter within 30 days after we receive your complaint. Our letter will tell you the medical or plan benefit reason for our decision. If you have a complaint about an emergency or hospital stay, you will have a decision in one business day. Requirements and timelines for filing a Complaint. You can file a complaint at any time either by calling Sendero s Customer Service department at or by writing to Sendero at: 2028 E. Ben White Blvd Suite 510 Austin, TX Information on how to file a complaint with HHSC once I have gone through the Sendero process: Once you have gone through the Sendero s complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free If you would like to make your complaint in writing, please send it to the following address: Texas Health and Human Services Commission Health Plan Operations - H-320 PO Box Austin, TX ATTN: Resolution Services If you can get on the Internet, you can send your complaint in an to: What can I do if my doctor asks for a service for me that is covered but Sendero denies it or limits it? There may be times when the Sendero Medical Director denies these services. When this occurs, Sendero will send you a Notice of Action in writing of our decision. You may appeal this decision. To appeal these medical decisions, call Member Services at In order to ensure continuity of currently authorized services, you must file the appeal on or before the later of: 10 days following Sendero s mailing of the notice of Action, or the intended effective date of the proposed Action. You or your provider may appeal verbally or in writing. If a request for an appeal is received verbally, you or your provider will need to put the appeal in writing. If your provider sends us the appeal, you will need to sign that request.

3 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 have the option of asking Sendero to extend the appeal time up to 14 calendar days. How will I find out if services are denied? Sendero will notify you in writing within 3 days of the Medical Director denying the request. We will send you a letter explaining why the decision was made and how to appeal the decision. You or a person acting on your behalf (i.e.: doctor, relative, friend, lawyer, or any other person), have the right to Sendero s internal appeal process. You can either call Sendero s Customer Service Coordinator at for help in completing the Appeal Request form or you can fill out and send in the enclosed Appeal Request form by mail to: Sendero Health Plans Attn: Member Advocate / Compliance Director Ste E. Ben White Blvd., Toll-free phone: All appeal requests must be submitted on this form. If there is any other information you would like for Sendero to consider when reviewing your appeal, please include it with this form. Sendero must have this completed form within 30 days of the date on this notice to move forward with your appeal. We will send you a letter letting you know when Sendero Health Plans has received your appeal (along with a copy of the appeal form if you have asked for an appeal by phone), within one week of the appeal form arriving in our office Appeals are reviewed by a doctor who was not involved in the original denial decision. You will receive a response to your appeal within thirty (30) calendar days of receipt of the appeal. If the decision results in stopping or reducing current services and you want them to keep going, you must ask for an extension of the services and file the appeal on or before ten (10) days after the date of this notice or the date the notice says your services will end, whichever is later. 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 Sendero Health Plans first decision. If the decision on your appeal reverses our first decision, Sendero Health Plans will pay for the services you received while your appeal was pending. You may ask for a Medicaid fair hearing from the State any time during or after the appeal process unless you have asked for an expedited appeal.

4 If you or your doctor feels that this denial of services will seriously jeopardize the member s health, you or your doctor may request an Expedited Appeal. You may obtain an Expedited Appeal by contacting Sendero Health Plans Senior Care Coordinator toll free at All Sendero Health Plans Expedited Appeal processes must be used prior to requesting an Expedited Fair Hearing. Once an Expedited Appeal has been requested and is determined to be an urgent situation, a decision is made within three (3) business days. If your appeal relates to an ongoing emergency or denial of continued hospitalization Sendero Health Plans will complete the investigation and resolution of the appeal within one (1) business day after receiving your request for an Expedited Appeal. Expedited Appeals can be extended up to fourteen (14) calendar days if you or your authorized representative or Sendero Health Plans (with HHSC approval) determine if there is a need for additional information that would best serve the member s interest. If you disagree with Sendero Health Plans decision, you have the right to ask for a Medicaid fair hearing from the Texas Health and Human Services Commission (HHSC). You may represent yourself at the fair hearing, or name someone else to be your representative. This could be a doctor, relative, friend, lawyer or any other person. You may name someone to represent you by writing a letter to Sendero Health Plans telling us the name of the person that you want to represent you. If you want to challenge a decision made by Sendero Health Plans, you or your representative must ask for the Medicaid fair hearing <insert date that is 90 after the date of the notice>. If you do not ask for the fair hearing by this date, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should write or call: Sendero Health Plans Attn: Fair Hearing Coordinator / Member Advocate Ste E. Ben White Blvd., Toll-free phone: If you believe that waiting for a hair fearing 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 expedited fair hearing by writing or calling Sendero Health Plans. To qualify for an expedited fair hearing through HHSC, you must first complete Sendero Health Plans internal appeals process. Time Frames If you ask for a fair hearing by within 10 days after the date of the notice or (2) the intended effective date of the action, you may be able to keep getting service or benefit that is being terminated, suspended, or reduced by Sendero Health Plans, at least until the fair hearing

5 decision is made. If you do not request a fair hearing by this date, the service or benefit will be terminated, suspended, or reduced. If you lose you fair hearing appeal, Sendero Health Plans may be able to collect from you the costs of providing the service or benefit to you while the appeal was pending. 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 hearings are held by telephone. You can also contact the HHSC hearings officer if you would like the hearing to be held in-person. During the hearing, you or your representative can tell why you need the service or why you disagree with the Sendero Health Plans action. You have the right to examine, at a reasonable time before the date of the fair hearing, the contents of your case file and any documents to be used by Sendero Health Plans at the hearing. At least one week before the hearing, Sendero Health Plans will send you all the documents to be used at the hearing. HHSC will give you a final decision within 90 days from the date you asked for the hearing. You may qualify for free or low cost legal services. A list of legal aid providers that may be able to help you is included Can someone from Sendero help me file an appeal? Yes. Contact Member Services at Can I file an appeal with the State? 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 may 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 request a hearing within 90 days, you lose your right to a hearing. See information below about how to ask for a State Fair Hearing. 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 may I ask for an Expedited Appeal? Does my request have to be in writing? Call Sendero Customer Services at to request an expedited appeal. You may request an expedited appeal orally or in writing. Sendero Health Plans Attn: Fair Hearing Coordinator / Member Advocate Ste E. Ben White Blvd.,

6 Toll-free phone: Who can help me file an Expedited Appeal? If you need assistance in filing this appeal, contact Customer Services at and they will contact a Member Advocate to help you. We will review your case and get back to you no later than 3 working days after we receive your request. What are the timeframes for an expedited appeal? We will review your case and get back to you no later than 3 working days after we receive your request. What happens if Sendero denies your request for an expedited appeal? You may discuss your request for an expedited appeal with the Medical Director if there are questions. Requests for expedited appeal are very serious. We want to make sure you or your child receive the care that is medically necessary. STATE FAIR HEARING STATE FAIR HEARING 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 90 days of the date on the health plan s letter with the decision. If you do not ask for the fair hearing within 90 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 (address for health plan) or call (number for health plan). 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: (1)10 days from the date you get the health plan s decision letter, or (2) 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.

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