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Physician/Provider Information and Advice for Physicians and Providers- Resources

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Where to file Medicare, Medicaid, and other health plan complaints

Children's Health Insurance Program (CHIP)

Complaints involving CHIP health maintenance organizations (HMOs) claims issues should be directed to the:

Texas Department of Insurance
Consumer Protection
(111-1A)
P. O. Box 149104
Austin, TX 78714-9104

Other CHIP complaints should be directed to the:

Health and Human Services Commission
Customer Service/Provider Relations,
H-610
1100 W. 49th Street
Austin, TX 78756-3172
512-338-6569
provider.resolutions@hhsc.state.tx.us

Federal Employees (including Postal Workers)

Federal employees' benefit plans fall under the authority of the federal government. These types of complaints should be sent to:

United States Office of Personnel Management
Insurance Service Division
Health Insurance Group
1900 E Street, NW Grp, Room 3435
Washington, DC 20415

State Employees

Article 3.50-2(4B) of the Texas Insurance Code, indicates that the Employee Retirement System (ERS) handles complaints regarding state employee's health insurance. Complaints involving state of Texas employees --including those who have elected HMO coverage -- should be directed to:

Employees Retirement System
Group Health Coverage

P. O. Box 13207
Austin, Texas 78711
512-476-6431

TASB (Texas Association of School Boards)

TASB is a self-funded plan established under the authority of Section 21.922 of the Texas Education Code. The law allows the TASB to regulate its own insurance program. You should direct these types of matters to one or both of the following entities:

Texas Association of School Boards
P. O. Box 2719
Austin, TX 78768

Commissioner of Education
Texas Education Agency

1701 North Congress
Austin, TX 78701

TRICARE Standard

TRICARE Standard (formerly CHAMPUS) is a federal program for active and retired military personnel and dependents. It falls under the regulatory authority of the U. S. Department of Defense in Aurora, Colorado, and is administered by Humana Military Healthcare Services. Therefore, we suggest that you send your complaint or appeal to:

For claims:
TRICARE South Region
Claims Department
P. O. Box 7031
Camden, SC 29020-7031

1-800-403-3950 (families and providers)
1-803-713-0354 (fax)
Hours of operation are Monday - Friday
8:00 a.m. to 6:00 p.m.

For correspondence:
TRICARE South Region

Customer Service Department
P. O. Box 7032
Camden, SC 29020-7032

1-800-444-5445 (Humana Military Tricare South)

For further assistance after contacting the number above, email trosouthcs@tros.tma.osd.mil
or call 1-800-554-2397
www.mytricare.com
www.humana-military.com

TRICARE HMO Option

If the complaint or appeal involves a TRICARE HMO plan, we suggest you send it to:

Medical Director
CHAMPUS FHFS TRICARE Grievances

7800 IH-10 West, Suite 30
San Antonio, TX 78230

1-800-406-2832

TRS-CARE (Teacher Retirement System of Texas)

TRS-Care is a state program authorized under Article 3.50-4 of the Texas Insurance Code. The law provides that the Teacher Retirement System handle complaints regarding the TRS-Care program. Complaints of this type should be forwarded to:

Group Insurance Division
Teacher Retirement System of Texas

1000 Red River Street
Austin, Texas 78701

512-397-6400

University of Texas Employees

The Texas Insurance Code (Article 3.50-3) provides that the University of Texas System regulates the self-funded plan that insures employees of all the University of Texas campuses. Please send these complaints to:

UT System Employer Group Insurance Program
Attn: Laura Chambers, director of Office of Employee Benefits
702 Colorado Street, Suite 6-600
Austin, TX 78701

512-499-4616
512-499-4620 (fax)

Other Governmental Employees (county, city, and school districts)

Local governments and political subdivisions are authorized to establish risk pools under the Local Government Code. The law allows municipalities or counties to regulate their own insurance programs.

To file an appeal under a local government health plan, you will need to send a written appeal to the address given in your patient's benefit booklet.

Medicaid

As Medicaid is a federally funded program, we suggest that medical providers contact either the Texas Health and Human Services Commission (HHSC) or Texas Medicaid & Healthcare Partnership (TMHP) to file an appeal or grievance. Providers may contact HHSC at the following address:

Texas Health and Human Services Commission
Mail Code 91X
P.O. Box 204077
Austin, TX 78720-4077

TMHP Contact Center is available during the hours of 7 a.m. to 7 p.m., Central Time, Monday through Friday and assists with questions such as provider enrollment procedures, claims filing procedures, and policy information. Providers may also contact TMHP at the following address:

Texas Medicaid and Healthcare Partnership
Claims

P.O. Box 200555
Austin, TX 78720-0555

1-800-925-9126
www.tmhp.com/Pages/default.aspx?sdupgwelredir=1

Medicare

If your complaint involves a Medicare claims issue, please be aware that those issues fall under the authority of the U. S. Department of Health and Human Services (Social Security Administration).

We have been informed that if our Texas citizens have a claims payment problem with Medicare, they should contact Novitas Solutions, Inc. We suggest that you contact Novitas Solutions, Inc at: www.novitas-solutions.com

Medicare Risk (HMO)

If your complaint involves a Medicare Health Maintenance Organization, please know that Medicare HMOs fall under the jurisdiction of the U. S. Department of Health and Human Services, Health Care Financing Administration (HCFA).

HCFA has informed us that complaints involving Medicare Risk plans (also known as Medicare+Choice plans) are to be directed to the HMO that issues the coverage. The HMO is responsible for ensuring that Medicare Risk complaints undergo the appropriate Federal grievance and appeals processes.

Questions concerning Medicare or Medicare Risk HMOs should be directed to the Medicare Hotline phone number

1-800-638-6833

Self-Funded Employee Benefit Plans

Individual employers and certain employee organizations may self-fund their employee health benefit plans under the authority of the Employee Retirement Income Security Act (ERISA), a federal law. ERISA preempts state regulation of these self-funded plans; however, the U.S. Department of Labor has some oversight of these plans.

If you have additional questions, you may contact the U.S. Department of Labor at:

U. S. Department of Labor
Division of Technical Assistance and Inquiries

PWBA N5619

200 Constitution Ave. NW
Washington DC 20210
1-866-444-3272

Examples of companies that have self-funded their benefit plans include: Motorola, IBM, Wal-Mart, HEB, Texaco, and AMD.



For more information contact:

Last updated: 11/08/2014

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