Important information about authorizations and appeals

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1 Annual NEWSletter Important information about authorizations and appeals 2013 A publication of for CHIP and STAR members and their parents. Sometimes the care you get from your doctor needs prior approval. In that case, your doctor will submit a request for approval. If a request is denied by Texas Children s Health Plan, you will get a letter noting the reason it was denied. You have the right to appeal a denial. will make a decision within 30 days of getting your request. To appeal you can represent yourself, or you may be represented by another person such as: Your doctor. A friend. A relative. Legal counsel. Another person. STAR members should send all appeals to: Attn: Appeals Department P.O. Box , NB 8390 Houston, Texas or CHIP members should send all appeals to: Attn: Appeals Department P.O. Box , NB 8390 Houston, Texas or Sometimes the appeal time frame could risk you or your child s life, health, or ability to recover a function. Your doctor will let us know if this is a possibility. In this event, you can request an expedited appeal. will make a decision within 3 working days of getting the request. If you want benefits to continue while the request is pending, call the number listed above. Please note that if the denial is upheld, you will need to pay the cost of services you get after the date of the original denial. STAR members may ask for a Fair Hearing. You have 90 days from the date the denial letter is received to request a Fair Hearing. The instructions for how to do this are included with the denial letter. If you have questions, call us at the above number. 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 done by phone. At that time you or your representative can tell why you need the service that was denied. Texas Health and Human Services Commission (HHSC) will give you a final decision within 90 days from the date you asked for the hearing. Pregnancy Gift Program Great news for pregnant members! Throughout the year, we have lots of classes about newborn care and pregnancy. Come to these classes and get a free $20 gift card. You can get up to 4 gift cards and can use them for baby supplies. To learn more, call our Member Services at Get extra care for your feet! STAR members ages 21 and older may be able to get extra foot care. Adult members get up to 2 extra podiatry visits per year that include nail exams and care. To learn more, call our Member Services at MK

2 How your plan works Do you have questions about how your plan works? Your member handbook has the answers. In your member handbook, you can find information on: Benefits and services. Drug management procedures. Copayments and other charges. Benefit limits that apply to services you get outside the Texas Children s Health Plan service areas. How to get language help. How to get information about doctors who are in Texas Children s Health Plan s network. How to get primary care services. How to get specialty care, behavioral health care, and hospital services. How to get care after normal office hours. How to get emergency care. How to get care and coverage when out of Texas Children s Health Plan s service areas. How to voice a complaint. How to appeal a decision that affects coverage, benefits, or your relationship with Texas Children s Health Plan. How Texas Children s Health Plan decides to add new covered benefits. Find your member handbook at You can also call member services at (CHIP) or (STAR). Assurance Wireless Lifeline Assistance Stay connected with a FREE cell phone and 250 FREE voice minutes! You may qualify to get: A FREE phone with 250 FREE voice minutes and 250 FREE texts. No yearly contract. Free calls to. Free health reminder text messages from. Nationwide Sprint network coverage. Voic , call waiting, and caller ID. 911 access. Go to or call our Member Services department at (CHIP) or (STAR) to learn more. Know your rights Did you know that as a member, you have rights and responsibilities? It s important that you know these. Knowing your rights and responsibilities can help you, your doctor, and make sure that you get the health care you need. Read about them at member-handbook.aspx. member-handbook.aspx. We care about your privacy Your privacy is important to us. You can view Texas Children Health Plan s privacy statement on how your medical information may be used by visiting our website at (CHIP) (STAR) Page 2

3 Utilization Management Affirmative Action Statement People sometimes do not know what Utilization Management (UM) programs do. Our UM team reviews the care of our members. We make sure that decisions are made because they are what our policies say we will do. There are no financial incentives for us or providers. UM makes decisions based on if the care and service is proper. It is also based on if the member has coverage. We do not reward people for denying coverage. And the payments we give do not encourage decisions that result in denial of care. How to Contact Utilization Management Utilization Management (UM) staff is ready for your calls from 6 a.m. to 6 p.m., Monday through Friday. You can call us, during normal office hours, for questions about the UM process. We can also give you information about a UM transaction. Just call Member Services at (CHIP) or (STAR). Member Services will route you to a UM staff member. If you need to leave a message by phone or , please do so any time. Our team will respond by the next business day. offers Text Telephones/ Telecommuncation Device for the Deaf (TTY/TDD) help for members who are: Deaf. Hard of hearing. Speech impaired. If you have questions about decisions made by Utilization Management, please send them to: CHIP members: Attn: Utilization Management Department P. O. Box , NB 8390 Houston, TX or FAX: STAR members: Attn: Utilization Management Department P. O. Box , NB 8390 Houston, TX or FAX We offer pest control services! Select members with asthma can now get free pest control for their home. To get free pest control from Texas Children s Health Plan, you or your family must: Have asthma. Own your home. Be part of the asthma management program. Members who have asthma and have been in the hospital or received emergency center care will be considered for this program. To learn more, call Member Services at Get your school and camp physicals. Great news! If you need to get a physical for school or camp, we ve got your covered. You can get school and camp physicals every year from your main doctor. These services are offered for: CHIP members ages 19 and younger. STAR members ages 21 and younger. For more information call our Member Services at (CHIP) (STAR) Page 3

4 Help us stop fraud, abuse, and waste We are glad you are a part of the Texas Children s Health Plan family. We need to discuss a very important item with you health-care fraud. Health-care billing mistakes happen a lot. The rules that doctors and hospitals must follow are very tricky. It is no wonder that billing mistakes happen in a busy doctor s office or emergency room. We know most of the doctors and hospitals want to do what is right. They want to follow the rules and take care of your family. But, there are some people that want something for nothing. You may have read about hospitals and providers that have cheated the system. They billed for services they did not do, or worse. We need your help to stop this. The state of Texas allowed Texas Children s Health Plan to start a program to find and stop fraud, abuse, and waste. These terms mean: Fraud: Knowingly submitting false claims in order to get payment. Abuse: Taking advantage of loopholes in the law to increase payments. Waste: Making too many payments due to poor training and education. Fraud, abuse, and waste hurt everyone. It raises taxes. It reduces funds ready to pay benefits. It may even reduce the quality of care. Some examples of fraud you might see include: Providers billing for services your family did not receive. Billing for different services than what you received. Asking for your member ID number when you are not going to the clinic or hospital. Offering money for your member ID number. Offering prizes or payments for you to come to a clinic or hospital. Be on the lookout for common scams such as: Statements that Your health plan wants you to have this service. Telemarketing or door-to-door salespeople offering medical services. Saying that the more tests that are done, the cheaper they are for the government. To help us prevent fraud, follow some of these tips: Don t give out your member ID number to anyone you do not know. Give it only to your doctor or hospital. Don t ask for services you don t need. Be careful of anyone saying, The services are FREE, so you should use my clinic. Can members commit fraud? Some members do commit fraud. They might change doctors to feed a bad habit. They might ask for services they do not need. Or, they may lie to a doctor. Some may even work with a doctor to commit fraud in return for money. Member fraud is against the law. Member fraud could result in losing your benefits. Or worse, it could mean fines or jail. What is the False Claims Act? The False Claims Act penalizes any person who submits a medical claim to the federal government that he or she knows is false. What is Whistleblower Protection? A whistleblower is a person who reports misconduct against a person or business that has committed fraud. Under federal law, whistleblowers are protected, among other things, from being threatened, harassed, or discriminated against. What if you suspect fraud? Contact us immediately. Do not wait more than one day. The Fraud Hotline Fax number us at : TCHPFraudandAbuse@texaschildrens.org. Or send a letter to: Fraud and Abuse Investigations Mail Code NB-8302/PO Box Houston, TX You do not have to give your name. Just tell us why you think there is fraud. Give us the name of the provider. And, tell us what you are worried about. We will take your questions seriously. We will investigate every case. We may even send your concern to the state. Most often, we will teach the provider what they did wrong. Please help us! wants to identify and prevent fraud. We need and appreciate your help! Call us with any questions (CHIP) (STAR) Page 4

5 About Drug Formularies What is a Drug Formulary? The formulary is a list of drugs chosen by doctors and pharmacists on the basis of quality and therapeutic value. It is a guide for doctors to know which drugs are covered. It includes brand name drugs and generics. Who decides what drugs are on the formulary? Formulary drugs are picked by a group of doctors and pharmacists. Only drugs that are safe, effective, and affordable are picked to be on the list. The group also selects drugs based on therapeutic value, side effects, and costs as compared to like medicines. Where can I go to find out what drugs are covered? Your formulary is on the Navitus website at You can search for a certain drug. You can also browse through lists of drugs. Also included is information about which drug needs prior approval and/or have quantity limits. It does not list every covered drug. The coverage or tier for each drug product is noted. But the dollar amount you pay for each drug is not listed. Contact Texas Children s Health Plan for your drug co-pay information. How do I file a complaint or an appeal for medications ordered by my doctor? The doctor will work with Navitus to request an exception to the formulary if needed. You have the right to appeal if you do not get an exception. When you have a concern about a pharmacy benefit, claim, or other service, please call at If your issue or concern is not resolved, you have the right to file a written appeal. 5 Steps to Safer Health Care Patient fact sheet Patient safety is one of the most pressing health care challenges. A 1999 report by the Institute of Medicine estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of lapses in patient safety. This fact sheet tells what you can do to get safer health care. It was created by the U.S. Department of Health and Human Services in partnership with the American Hospital Association and the American Medical Association. 1. Ask questions if you have doubts or concerns. Ask questions and make sure you understand the answers. Choose a doctor you feel comfortable talking to. Take a relative or friend with you to help you ask questions and understand the answers. 2. Keep and bring a list of ALL the medicines you take. Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines. Tell them about any drug allergies you have. Ask about side effects and what to avoid while taking the medicine. Read the label when you get your medicine. And read all the warnings. Make sure your medicine is what the doctor ordered and know how to use it. Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure. Ask when and how you will get the results of tests or procedures. Don t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. Call your doctor and ask for your results. Ask what the results mean for your care. 4. Talk to your doctor about which hospital is best for your health needs. Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from. Be sure you understand the instructions you get about followup care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, Who will manage my care when I am in the hospital? Ask your surgeon: Exactly what will you be doing? About how long will it take? What will happen after the surgery? How can I expect to feel during recovery? (CHIP) (STAR) Page 5

6 FREE family membership at Baker-Ripley Neighborhood Centers Inc (NCI)! ($100 value) The NCI family membership is $100, but you get it for FREE! Just say you are a member. That s it! You and your family can enjoy and benefit from: Computer classes. Cooking classes. Healthy eating classes. School coaching. Summer day camps. Immigration workshops. Much more! If you have questions, call our Member Services at (CHIP) or (STAR). Look for our event calendar on the web to learn of fun events near you. Go to Baker-Ripley Neighborhood Center 6500 Rookin St. Houston, TX (CHIP) (STAR) Page 6

7 How to contact Case Management, Disease Management, and Women s Health Services Case Managers can be reached by phone or fax during normal office hours from 8 a.m. to 4:30 p.m. They offer care coordination to you and your kids. You can find the phone and fax numbers below. Asthma Diabetes Obesity Women s Health Program CHIP Member Services Phone: STAR Member Services Phone: Nurse Family Partnership Phone: Healthy Families America CHIP Member Services Phone: STAR Member Services Phone: Special Needs ADHD CHIP Member Services Phone: STAR Member Services Phone: Life Care Planning Life Care Planning offers families peace of mind. If you are no longer able to be a caregiver, Life Care Planning can help. Texas Department of Aging and Disability Services: Advance Directive Resources Directive to Physicians and Family or Surrogates Disclosure Statement for Medical Power of Attorney Annual Newsletter Annual Newsletter is published annually by All rights reserved. P.O. Box , NB (CHIP) (STAR) Page 7