Texas – CHIP - Frequently Asked Questions

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Children's Health Insurance Program (CHIP)

Frequently Asked Questions

Q.
What should I do in an emergency?
A.

If you have an emergency, go immediately to the closet Emergency Room (ER) at the nearest hospital. If you need help getting to the ER fast, call 911. You do not need a referral from your PCP to use the ER.

Q.
What if I move?
A.

You can call the CHIP/Children's Medicaid Hotline and tell a customer care representative what your new address is. That toll-free number is 1-877-KIDS-NOW (1-877-543-7669). The hotline is open from 8 a.m. to 8 p.m. Monday through Friday, except for federal holidays.

You will also need to call your child's CHIP health plan to make sure their files have your new address.

Q.
What should I do if I get a medical bill?
A.

Sometimes you will get a bill that should have been sent to us. If you get a bill you believe we should pay, call Customer Service for help. You may have to pay medical bills if you receive treatment from doctors who are not part of the CHIP network.

Q.
How do I get a doctor's appointment?
A.

Call your Primary Care Physician (PCP) office. Your doctor's name and phone number are shown on your Plan ID card. Give the office the following information:

  • Your primary care physician's name
  • Your name
  • Your enrollee ID number on your Plan ID card
  • The name of the person who needs to see the doctor
  • Why you need to see the doctor. If you feel you need to see the doctor right away, tell this to the person who answers the phone.
Q.
What are my rights and responsibilities?
A.

Member Rights

Members Have the Right to:

1. You have a right to get accurate, easy-to-understand information to help you make good choices about your unborn child’s health plan, doctors, hospitals and other providers.

2. You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work.

3. You have a right to know how the health plan decides whether a Perinatal service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.

4. You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses.

5. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed.

6. You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan.

7. You have the right and responsibility to take part in all the choices about your unborn child’s health care.

8. You have the right to speak for your unborn child in all treatment choices.

9. You have the right to be treated fairly by the health plan, doctors, hospitals and other providers.

10. You have the right to talk to your Perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records.

11. You have the right to a fair and quick process for solving problems with the health plan and the plan’s doctors, hospitals and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.

12. You have a right to know that doctors, hospitals, and other Perinatal providers can give you information about your or your unborn child’s health status, medical care, or treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

 

Member Responsibilities

You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities.

1. You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet.

2. You must become involved in the decisions about your unborn child’s care.

3. If you have a disagreement with the health plan, you must try first to resolve it using the health plan’s complaint process.

4. You must learn about what your health plan does and does not cover. Read your CHIP Program Handbook to understand how the rules work.

5. You must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and cancel it.

6. You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans.

7. You must talk to your provider about your medications that are prescribed.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

Q.
What can I do if my child’s doctor asks for a service for my child that is covered but UnitedHealthcare Community Plan denies or limits it?
A.

UnitedHealthcare Community Plan will send you a letter if a covered service requested by your child’s PCP is denied, delayed, limited or stopped. If you are not happy with the decision, you can call Member Services at 1-888-887-9003 and ask for an appeal. We will record your verbal request. Your recording will then be made into a written request. We will send a form to you to complete, sign and return as soon as possible.

Q.
How will I find out if services are denied?
A.

UnitedHealthcare Community Plan will send you a letter if a covered service requested by your child’s PCP is denied, delayed, limited or stopped.

Q.
What are the timeframes for the appeal process?
A.

UnitedHealthcare Community Plan has up to 30 calendar days to decide if your request for care is medically needed and covered. We will send you a letter of our decision within 30 days. In some cases you have the right to a decision within one business day. If your provider requests, we must give you a quick decision. You can get a quick decision if your health or ability to function could be seriously hurt by waiting. You also have the right to choose a quick review from an Independent Review Organization (IRO).

Q.
When do I have the right to request an appeal?
A.

You may request an appeal whenever you do not agree with UnitedHealthcare Community Plan’s decision to deny services or care for you/your child.

Q.
Does my request have to be in writing?
A.

An appeal form will be included in each letter you receive when UnitedHealthcare Community Plan denies a service to you. This form must be signed and returned. You may request an appeal by phone, but an appeal form will be sent to you, which must be signed and returned.

Q.
Can someone from UnitedHealthcare Community Plan help me file an appeal?
A.

Member Services is available to help you file an appeal. You can ask them to help you when you call 1-888-887-9003. They will send you an appeal request form and ask that you return it before your appeal request is taken.

Q.
What is an Expedited Appeal?
A.

An Expedited Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

Q.
How do I ask for an Expedited Appeal?
A.

You may ask for this type of appeal in writing or by phone. Make sure you write “I want a quick decision or an expedited appeal,” or “I feel my child’s health could be hurt by waiting for a standard decision.”

To request a quick decision by phone, call UnitedHealthcare Community Plan Member Services at 1-888-887-9003.

Q.
Does my request for an Expedited Appeal have to be in writing?
A.

We can accept your request orally or in writing. Mail written requests to:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
PO Box 31364
Salt Lake City, UT 84131-0364

Q.
What if I have a complaint? What should I do if I have a complaint? Who do I call?
A.

We want to help. If you have a complaint, please call us toll-free at 1-888-887-9003 to tell us about your problem. A UnitedHealthcare Community Plan Member Services Advocate can help you file a complaint. Just call 1-888-887-9003. Most of the time, we can help you right away or at the most within a few days.

Q.
If I am not satisfied with the outcome, who else can I contact?
A.

If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance by calling toll-free to 1-800-252-3439. If you would like to make your request in writing, send it to:

Texas Department of Insurance
Consumer Protection
P.O. Box 149091
Austin, TX 78714-9091

If you can get on the Internet, you can send your complaint in an email to http:www.tdi.texas.gov/consumer/complfrm.html.

Q.
Can someone from UnitedHealthcare Community Plan help me file a complaint?
A.

Yes, a UnitedHealthcare Community Plan Member Services representative can help you file a complaint, just call 1-888-887-9003. Most of the time, we can help you right away or at the most within a few days.

Q.
How long will it take to process my complaint?
A.

Most of the time we can help you right away or at the most within a few days. You will get a response letter within 30 days from when your complaint got to UnitedHealthcare Community Plan.

Q.
Do I have the right to meet with a Complaint Appeal Panel?
A.

If you make a complaint for you/your child and it is not worked out the way you thought it should, you have the right to appeal. When you appeal, you will get information about having your concern heard by a Complaint Appeal Panel. This panel is made up of doctors, other providers, and UnitedHealthcare Community Plan members.

Q.
What are the requirements and timeframes for filing a complaint?
A.

There is no time limit on filing a complaint with UnitedHealthcare Community Plan. UnitedHealthcare Community Plan will send you a response letter telling you what we did about your complaint.

Q.
Where can I mail a complaint?
A.

For written complaints please send your letter to UnitedHealthcare Community Plan. Your letter must state your name, your member ID number, your telephone number and address, and the reason for your complaint. Please send your letter to:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
PO Box 31364
Salt Lake City, UT 84131-0364

Ombudsman Program

UnitedHealthcare Community Plan members can access a UnitedHealthcare Community Plan Independent Ombudsman to assist them with resolving their complaint

Q.
What if my ID card is lost or stolen?
A.

If you lose your/your child’s UnitedHealthcare Community Plan ID card, call Member Services right away at 1-888-887-9003. Member Services will send you a new one. Call TDD/TTY 711 for hearing impaired. 

Q.
What is a Member Advisory Group?
A.

A member advisory group is a group of members that help give suggestions to make the health plan better. If you would like to join the advisory group in your area, call Member Services.

Q.
How much are copays and when do I have to pay them?
A.

Copayments for medical services or prescription drugs are paid to the health care provider at the time of service. You do not have to pay copayments for preventive care such as well-child or well-baby visits or immunizations. Your/your child’s UnitedHealthcare Community Plan card lists the copayments that apply to your family. Present your card when you/your child get office visits or emergency room services or has a prescription filled. There are no copayments for CHIP Perinate Program members. 

Questions?

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Children's Health Insurance Program (CHIP)