For Members | Texas Children's Health Plan
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For Members

 

At Texas Children’s Health Plan, we go far beyond to provide the best quality care.

We understand that our members may have some questions or concerns. To help, we’ve compiled some helpful information and services that better serve our diverse member population, customized to fulfill our member’s needs.

Click on each category below to learn more on what we can assist you with.

 

Helpful Information

Our Member Services Team is ready to take your call from 8 a.m. to 5 p.m., Monday through Friday. After hours, on weekends and holidays, our answering service is ready to help you and/or take your messages. A Member Service Advocate will return your call the next business day. We speak English or Spanish. We also have interpreters available by phone who speak 140 different languages. Emergency Service and Behavioral Health services are available 24 hours a day, 7 days a week.
 
Here are some services our team can help you with, if needed.
 
  • Oral interpretation (over the phone and face to face) and written translations assistance. Sign language available.
  • Information in formats such as print, Braille, audiotapes or accessible electronic.
  • Access to TTY/TDD services for hearing and speech impairment
  • To join, you can call: 1-877-782-6440 (STAR Kids) or 1-800-964-2777 (CHIP and STAR). For TTY/TDD call 1-800-735-2989.

Member Services Program Hotlines:

  • CHIP: 1-866-959-6555
  • STAR: 1-866-959-2555
  • STAR Kids: 1-800-659-5764 (Service Coordination)
  • TTY/TDD: 1-800-735-2989 (Texas Relay) or 7-1-1
In case of an emergency, go to your nearest in-network emergency room or call 9-1-1.

HHSC continues to require of Texas Children’s Health Plan to allow an extension for up to 30 days for members to request continuation of benefits after they receive an adverse benefit determination. This continuation of benefits extension time frame will end June 30, 2021.

Starting July 1, 2021, Texas Children’s Health Plan must apply the normal, regular and set timeframes for members to request continuation of benefits, which is no later than 10 days from the date they receive the adverse benefit determination notice.

Texas Children’s Health Plan provides a Member Advocate to assist you if you have a complaint. Our team of member advocates will help you write and file a complaint or appeal on your behalf and monitor it until it is resolved. We have a member advocate dedicated for each line of business and service delivery area. We speak English and Spanish. We also have interpreters available by phone who speak 140 different languages.

To have a Member Advocate assigned to you, call 866-219-5411.

Can a Member ask for an External Medical Review?
 
If a Member, as a member of the health plan, disagrees with the health plan’s internal appeal decision, the Member has the right to ask for an External Medical Review. An External Medical Review is an optional, extra step the Member can take to get the case reviewed before the State Fair Hearing occurs. 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’ provided as an attachment to the Member Notice of MCO Internal Appeal Decision letter and mail or fax it to Texas Children’s Health Plan by using the address or fax number at the top of the form.
 
Texas Children's Health Plan
Attn: UM Department
P.O. Box 301011, WLS 8390
Houston, TX 77230-1011
Fax: 832-825-8796
 
Call Texas Children’s Health Plan at 866-959-2555 (STAR) or 800-659-5764 (STAR KIDS) or email us at TCHPUM@texaschildrens.org 
 
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. 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 Texas Children’s Health Plan at 866-959-2555 (STAR) or 800-659-5764 (STAR KIDS) or 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.
 
Can I ask for an emergency External Medical Review?
 
If you believe that waiting for a standard External Medical Review will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you, your parent or your legally authorized representative may ask for an emergency External Medical Review and emergency State Fair Hearing by writing or calling Texas Children’s Health Plan. To qualify for an emergency External Medical Review and emergency State Fair Hearing review through HHSC, you must first complete Texas Children’s Health Plan internal appeals process.

Regular checkups and shots keep your children healthy. You can go to any Texas Health Steps doctor without a referral. To find a Texas Health Steps (THSteps) doctor near you, call us at 1-866-959-2555 or use our "Find a Doctor" tool.

For more information visit www.TXHealthSteps.com

Do not let other people use your/your child’s ID card. If the card is lost or stolen, call Member Services (toll-free) and a Member Advocate will send a new card to you.

CHIP: 1-866-959-6555
STAR: 1-866-959-2555
STAR Kids: 1-800-659-5764

Texas Children’s Health Plan will host quarterly Member Advisory Group meetings to gain valuable feedback from our current members on the initiatives, services, and programs offered by the health plan. The information and member feedback gathered during these meetings will be used to guide future programs.
 
The meetings are mandated by the state, and will last no longer than one hour. These groups help our diverse population by implementing cultural and linguistic services that meet their needs. TCHP must maintain a record of member advisory group meetings, including agendas, and minutes.
 
To join and learn more, call Care Coordination at 832-828-1430

A State Fair Hearing is a chance for you tell the reasons why you think the services you asked for and couldn’t get should be allowed.

Can I ask for a State Fair Hearing? If you, as a member of Texas Children’s 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 Texas Children’s Health Plan, you or your representative must ask for the fair hearing at any time up until 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 State Fair Hearing.To ask for a fair hearing, you or your representative should either send a letter to the health plan or call:

Texas Children’s Health Plan
Attention: Appeals Department NB8390
PO Box 300709
Houston, TX 77230
Fax: 832-825-8796
Phone: 832-828-1001 or 1-866-959-2555
TDD 1-800-735-2989 (Texas Relay) or 7-1-1

Click here for more information on State Fair Hearings

Here are some additional CHIP and Medicaid helpful links. Call our Member Services Hotline for further assistance or to request information.
 

CHIP Member Helpful Links

STAR Member Helpful Links

STAR Kids Member Helpful Links