STAR Complaints and Appeals Process

Filing a Complaint

If you have a complaint, please call us toll-free at 800-431-7798 to tell us about your problem. A FirstCare Member Services Advocate can help you file a complaint. Most of the time, we can help you right away or, at the most, within a few days.

If you don't get the help you need from FirstCare, you should do one of the following:

• Call the Medicaid Managed Care Helpline at 866-566-8989 (toll-free).
• Email your complaint to HPM_Complaints@hhsc.state.tx.us.
• Write to:
  Texas Health and Human Services Commission
  Office of the Ombudsman, MC H-700
  P.O. Box 13247
  Austin, TX 78711-3247
• Fax 806-784-4319 (toll-tree)

File a Complaint with HHSC

Once you have gone through the FirstCare complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 866-566-8989 (TTY 711) 8 a.m. to 5 p.m. CST weekdays. If you would like to make your complaint in writing, please send it to the following address:

Texas Health and Human Services Commission Ombudsman Managed Care Assistance Team
P.O. Box 13247
Austin, TX 78711-3247
Fax: 888-780-8099

If you can get on the Internet, you can submit your complaint at: hhs.texas.gov/managed-care-help.

Appeals Process

You have the right to appeal a decision if Medicaid covered services are denied based on lack of medical need. You can appeal a denial if you feel FirstCare denied, reduced, terminated coverage of your care or did not pay for your care.

You must request for an appeal within sixty (60) days from the date of your denial notice. You or your provider may send a verbal or written appeal. If you do not request for an appeal within sixty (60) days, you will lose the right to an appeal.

FirstCare will acknowledge, review, and send you a letter within thirty (30) days. The letter will inform you of the outcome of FirstCare's internal review. If the appeal is denied, the letter will include the next level of appeal rights.

If we need more time to review your appeal, we will notify you verbally followed by a letter within two (2) calendar days telling you why we need more time. The time frame will be extended to fourteen (14) days. If we need additional information, we will contact your doctor.

You may be able keep getting your services while your appeal is in process. You can also call FirstCare Health Plans at 800-431-7798/TTY 711 and say you want to keep your services during your appeal. You must make this request within 10 days from the date of the denial notices is mailed or the date the services will change. If you don't ask for an appeal by this date, the service we denied will stop.

For oral appeals, please call Customer Service at 800-431-7798 (TTY 711) 24/7 to let us know you want to appeal an action. You can also submit your appeal in writing. If you need help, FirstCare can help you write your appeal by requesting a Member Advocate. Your written appeal should be mailed to:

FirstCare Health Plans
Attn: Complaints & Appeals
1206 W. Campus Drive
Temple, TX 76502
Fax: 806-784-4319

Expedited Appeals

You can expedite your appeal if waiting 30 calendar days would harm your health. We'll make a decision within 72 hours of receiving your appeal. If the appeal is related to an ongoing emergency or denial of a continued hospital stay, we'll make a decision within 1 business day of receipt. You can also call FirstCare Health Plans at 800-431-7798/TTY 711 for more information.

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

• Calling us at 800-431-7798/TTY 711;
• Mailing us at
  FirstCare Health Plans
  Attn: Complaints and Appeals Department
  1206 W. Campus Drive
  Temple, TX 76508
• Faxing us at 806-784-4319

You do not have a right to a State Fair Hearing and EMR if Medicaid does not cover the service you requested.

You may be able keep getting your services while your appeal is in State Fair Hearing or EMR process. You can also call FirstCare Health Plans at 800-431-7798/TTY 711 and say you want to keep your services during your appeal. You must make this request within 10 days from the date of the appeal denial notices is mailed or the date the services will change. If you don't ask for a state fair hearing by this date, the service we denied will stop.

Call 800-431-7798 if you need any help with any questions.

STATE Fair Hearing and External Medical Review

If you do not agree with FirstCare's decision, you may ask for a State Fair Hearing (standard or expedited) or State Fair Hearing with an External Medical Review (EMR) (standard or expedited) from the State. You cannot only ask for an External Medical Review. An EMR is an optional, extra step for the member to have a case outside the Hearing, free of charge. You may ask for a State Fair Hearing only after exhausting FirstCare's Internal Appeal process. You may name someone to represent you by writing a letter to the FirstCare telling them the name of the person you want to represent you. A provider may be your representative.

You have 120 days from the date on the letter to request a Fair Hearing or State Fair Hearing and EMR. If you do not ask for the State Fair Hearing or EMR within 120 days, you may lose your right to a State Fair Hearing and EMR.

EMR Process

An External Medical Review is an optional, extra step the Member can take to get the case reviewed before the State Fair Hearing occurs. 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.

If the Member has any questions about or would like to the check status of an External Medical Review, please contact FirstCare Health Plans at 800-431-7798/TTY 711.

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. An 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 Member's MCO at:

• FirstCare Health Plans
  Attn: Fair Hearing Request
  1206 W. Campus Drive
  Temple, TX 76508
• OR by phone at 800-431-7798 / TTY 711

...or the HHSC Intake Team at EMR_Intake_Team@hhsc.state.tx.us.

Fair Hearing

You may ask for a Fair Hearing only after exhausting FirstCare's Internal Appeal process. If you do not agree with FirstCare's decision, you may ask for a Fair Hearing from the State. You have 120 days from the date on the letter to request a Fair Hearing.

You can request a Fair Hearing by contacting FirstCare STAR at 800-431-7798.

If you would like to make your request in writing, please write:

FirstCare Health Plans
Attn: Complaints and Appeals Department
1206 W. Campus Drive
Temple, TX 76502

You do not have a right to a Fair Hearing if Medicaid does not cover the service you requested.

Call 800-431-7798 if you need any help.