Appeals and Grievances

TexanPlus^® HMO allows members to submit complaints to the plan which may become either an appeal or a grievance.

• What is an appeal?

  The process that enables independent review of adverse organization determinations.

  Per Medicare, an appeal is any procedure that deals with the review of adverse organization determinations on the healthcare services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the healthcare services (such that a delay would adversely affect the health of the member), or on any amounts the member must pay for a service. These procedures include reconsideration by the plan and if necessary, an independent review entity, hearings before Administrative Law Judges (ALJs), review by the Medicare Appeals Council (MAC), and judicial review.
• Members have additional options to expedite an appeal if his or her physician believes that waiting for a decision under the standard time frame could place their life, health, or ability to regain maximum function in serious jeopardy. An expedited appeal is a request for a pre-service or concurrent appeal that must be reviewed within 72 hours after we receive it. An expedited appeal can be requested verbally or in writing by you, an appointed representative or your treating physician. If the appeal request includes one of the following key words it will be considered an expedited appeal: Expedited, Fast, STAT, Urgent, ASAP, Rush, Immediate, Life Threatening. Note: Appeal requests for denial of payments cannot be expedited. Medicare Advantage plans have 72 hours to respond to an expedited appeal which can be extended to a total of 14 days.

• What is a grievance?

  A complaint or dispute that describes an enrollee’s dissatisfaction with the way the plan provides healthcare services, regardless of whether a remedy exists.

  Per Medicare, A grievance is any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which the plan or delegated entity provides healthcare services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to the plan. An expedited grievance may also include a complaint that the plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

  In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of healthcare.
• If a member or their representative is dissatisfied with the services provided, such as sales, enrollment, or service processes, they have the right to file a grievance with the plan. The plan will review the grievance, take necessary action, and notify the member or their representative. A grievance does not involve an appeal.
• An expedited grievance includes a complaint that the plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. The plan will respond to your expedited grievance within 24 hours.

Value-added services included with the plan do not have appeal rights; however, members may file grievances regarding value added-services received.

For more information about the appeals and grievances processes, please contact us at 1-800-958-2707, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week. You can find more information about what your plan covers in your Evidence of Coverage.

You may submit your complaint in writing to the plan to the following address:

• TexanPlus
  c/o Appeals and Grievances
  P.O. Box 742608
  Houston, Texas 77274
• Or Via Fax: 1-800-817-3516

If you wish to request an aggregate number of grievances, appeals and exceptions filed with TexanPlus, contact  us at 1-800-958-2707, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-958-2692) 7 days a week. Please refer to your Evidence of Coverage on Complaints in Chapter 2, Section 1 for more information on what to do next.

Our decision is final and cannot be appealed. However, you always have the option to make a complaint with Medicare

If you would like to submit your complaint to Medicare, click on the Medicare Complaint Form to access the form. Please note you do not have to use the Medicare Compliant Form to make a complaint to Medicare. Your options include:

• The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances and information requests.
• The Medicare.gov website for more information. Per Medicare regulations, all grievance decisions are final.
• Calling Medicare at 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week.

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