Medicaid Complaints
You have the right to file a complaint at any time. Please call Member Services and we will address your questions or concerns about benefits, services, access to appointments, wrong bills you received or other issues. If possible, we will resolve your problem at the time of your call. If that is not possible, we will ask for more information and get back to you within 30 calendar days after your complaint is filed. At any time, we may ask you for more information.
You can also file a complaint in writing. An authorized representative - someone you choose in writing - can help you. Your authorized representative can be a friend, neighbor, family member, provider or attorney.
Medicaid Complaint Process
What should I do if I have a complaint?
We want to help. If you have a complaint, please call us at 1-877-901-7321, TDD/TTY: 7-1-1 (toll-free) to tell us about your problem. A UnitedHealthcare Dental Member Services advocate can help you file a complaint. Most of the time, we can help you right away or within a few days at the most. To get status of a complaint, contact us at 1-877-901-7321, TDD/TTY: 7-1-1 (toll-free).
If you still have a complaint after you’ve gone through the UnitedHealthcare Dental’s complaint process, call the Texas Health and Human Services Commission (HHSC) at 1-866-566-8989 (toll-free). If you want 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, Texas 78711-3247
hhs.texas.gov/managed-care-help
We want to help. If you have a complaint, please call us toll-free at 1-877-901-7321, TDD/TTY: 7-1-1 to tell us about your problem. Send written complaints to:
UnitedHealthcare Dental Texas Children’s Medicaid
Appeals/Complaints Department
P.O. Box 1427
Milwaukee, WI 53201
Can someone from UnitedHealthcare Dental help me file a complaint?
A UnitedHealthcare Dental Member Services advocate can help you file a complaint. Just call 1-877-901-7321, TDD/TTY: 7-1-1.
What do I need to do to file a complaint and how long will the process take?
Please call us at 1-877-901-7321, TDD/TTY: 7-1-1 (toll-free) to tell us about your problem. A UnitedHealthcare Dental Member Services advocate can help you file a complaint. Or you can write to us at the address below. Most of the time, we can help you right away or within a few days at the most. Send written complaints to:
UnitedHealthcare Dental Texas Children’s Medicaid
Appeals/Complaints Department
P.O. Box 1427
Milwaukee, WI 53201
We will send you an acknowledgment letter less than 5 business days after we receive your complaint. The letter will also tell you what you can do if you still have concerns.
We will review your case and send you a letter with our decision within 30 days from the date of your complaint.
If I don’t like what happens with my complaint, who else can I call?
If you still have a complaint after you’ve gone through the UnitedHealthcare Dental ’s complaint process, call the Texas Health and Human Services Commission (HHSC) at 1-866-566-8989 (toll-free).
How can I file a complaint with HHSC after I have gone through the UnitedHealthcare Dental complaint process?
Call the Texas Health and Human Services Commission (HHSC) at 1-866-566-8989 (toll-free). If you want 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, Texas 78711-3247.
Medicaid Appeals
An appeal is a request to change a decision made by UnitedHealthcare Dental for services that you or your provider believe you are entitled to receive. You, or an authorized representative, can file an appeal in writing, in person, or by calling UnitedHealthcare Dental Texas Children’s Medicaid Member Services. Requests to review services that were denied by UnitedHealthcare Dental Texas Children’s Medicaid must be made within 60 calendar days of UnitedHealthcare Dental Texas Children’s Medicaid decision to deny a service or supply. We will review the care or services that were denied or the coverage decision that was made. Send written appeals to:
UnitedHealthcare Dental Texas Children’s Medicaid
Appeals/Complaints Department
P.O. Box 1427
Milwaukee, WI 53201
You have the right to:
Ask for and get copies of all documents related to the appeal. You may add information about the appeal to your file in writing or in person.
Continue to have Medicaid covered services while your appeal is under review. To have these Medicaid covered services continue, you must call or tell UnitedHealthcare Dental Texas Children’s Medicaid within 10 business days of being notified. If the appeal is denied, you may be responsible for the cost of any continued benefits you received. If the appeal is approved and you did not request that your services be continued while your appeal was pending, UnitedHealthcare Dental Texas Children’s Medicaid will authorize or provide services within 72 hours.
Qualified UnitedHealthcare Dental Texas Children’s Medicaid staff decide on appeals that are not about medical issues. Qualified health care professionals decide on appeals about medical issues. We will make a fair decision about appeals within 30 calendar days of receiving your appeal.
Can someone else appeal for me?
Yes. Your doctor, another provider or anyone you choose can ask for an appeal.
Appeal Process
What can I do if UnitedHealthcare Dental denies or limits a service for my child that the dentist has asked for?
If you do not agree with the UnitedHealthcare Dental denial, you have the right to appeal. You can ask UnitedHealthcare Dental to help you file an appeal. You can also choose a provider, a relative, a friend, or lawyer to appeal on your behalf. The person you choose must have your written approval to appeal on your behalf.
How will I find out if services for my child are denied?
You will receive notification of a denial for service(s) requested for your child in the mail. You can call Member Services at 1-877-901-7321, TDD/TTY: 7-1-1 for a status on a request for services for your child or view the status by logging into the member website. Your dentist may also tell you about the denial.
What are the timeframes for the appeal process?
You must ask for an appeal within 60 days from the date you get our denial letter. If you want UnitedHealthcare Dental to look at your case, you can ask for it by writing or by calling us. If you, or the person you choose to appeal for you call Member Services to ask for an appeal, Member Services will put your appeal in writing and send it to you to sign. You, or the person you choose to appeal for you must sign the appeal and send it back to us, unless you have requested a fast (expedited) appeal.
You can request an extension of up to 14 calendar days if needed. If UnitedHealthcare Dental determines there is need for more information or an extension is in your child’s best interest, we will notify you in writing. We will state how a delay is in your child’s best interest.
When can I ask for an appeal?
You must ask for an appeal within 60 days from the date you get our denial letter. Your services may continue while your appeal is being looked at, if all of the following apply:
You can ask for an appeal if:
- Within 10 calendar days from the date we mailed the denial letter, or
- Before the effective date of this denial letter.
- The appeal request is related to reduced or suspended services or to services that were previously authorized for you.
- The services were ordered by an authorized provider.
- The authorization period for the services has not ended.
- You asked that the service continue.
You can also ask for an appeal for partial or complete denial of payment for services. You can request an extension of up to 14 calendar days if needed. If UnitedHealthcare Dental determines there is need for more information or an extension is in your child’s best interest, we will notify you in writing. We will state how a delay is in your child’s best interest.
Can I just ask for an appeal or does it have to be in writing?
If you want UnitedHealthcare Dental to look at your case, you can ask for an appeal by writing or calling us. If you, or the person you choose to appeal for you call Member Services to ask for an appeal, Member Services will put your appeal in writing and send it to you to sign. You must ask for an appeal within 60 days from the date you get our denial letter. You, or the person you choose to appeal for you must sign the appeal and send it back to us, unless you have requested a fast (expedited) appeal. Send written appeals to:
UnitedHealthcare Dental Texas Children’s Medicaid
Appeals/Complaints Department
P.O. Box 1427
Milwaukee, WI 53201
Can someone from UnitedHealthcare Dental help me file an appeal?
Yes. Please call Member Services at 1-877-901-7321, TDD/TTY: 7-1-1 to ask for an appeal. Member Services will put your appeal in writing and send it to you to sign.
What else can I do if I’m still not happy?
If you disagree with UnitedHealthcare Dental ’s appeal decision, you have the right to ask for an External Medical Review with fair hearing. You, your parent, your authorized representative or your legally authorized representative (LAR) must ask for the External Medical Review within 120 days of the date the health plan mails the letter with the decision. You may request a standard External Medical Review with a State Fair Hearing or an emergency External Medical Review with State Fair Hearing either in written or oral form or External Medical Review. You must complete the UnitedHealthcare Dental ’s appeal process before you can ask for a State Fair Hearing.
Expedited Dental Plan Appeal
What is an expedited appeal?
Ask for an expedited appeal when you don’t have time for a standard appeal - when your child’s life or health is in danger. When you ask for an expedited appeal, UnitedHealthcare Dental has to make a decision quickly based on the condition of your child’s health.
How do I ask for an expedited appeal?
You can ask for an appeal by writing or calling us. If you, or the person you choose to appeal for you can call Member Services to ask for an expedited appeal.
How long does an expedited appeal take?
We will review and respond to your expedited appeal request within 72 hours.
What happens if UnitedHealthcare Dental says it won’t give me an expedited appeal?
If UnitedHealthcare Dental does not think delay in care is life threatening, we will let notify you within 72 hours. Your appeal will be processed through the standard appeal process. We will notify you of a decision within 30 days.
Who can help me file an expedited appeal?
You, your child’s doctor, another provider, or anyone you choose can ask for an expedited appeal.
State Fair Hearings and Medical Reviews
A state fair hearing is when the Texas Health and Human Services Commission (HHSC) directly reviews our decisions with your dental care.
If you ask for a state fair hearing, you can also ask for an external medical review where independent healthcare experts review your request to receive services. This review is an optional, extra step you can take to get your case reviewed for free before your state fair hearing. It doesn’t change your right to a state fair hearing.
Request a state fair hearing and external medical review by either:
- Filling out the attached State Fair Hearing and External Medical Review Request Form and mailing or faxing it to us using the address or fax number at the top of the form.
- The mailing address is:
UnitedHealthcare Dental- Texas
Attn: State Fair Hearings and External Medical Review
PO Box 740224
Atlanta, GA 30374-0224. - Calling us at 1-877-901-7321
- Emailing us at txdentaladvocates@uhc.com
- External Review Form
You must make a request for a state fair hearing with or without an external medical review with 120 Days from the date the appeal decision was mailed.
If you don’t ask for the state fair hearing with or without an external medical review by this date, you may lose your right to a state fair hearing. If you have a good reason, like receiving our notice late, we may be able to accept your appeal request after this date.
If you kept receiving services during your dental plan appeal, you may be able to continue your services during your state fair hearing.
Make a request to continue getting services within 10 Days from the date the appeal decision notice was mailed. If you don’t ask for a state fair hearing and to keep your services by then, you will not continue to get your services, but you still have 120 Days from the date the appeal decision notice was mailed to ask for a state fair hearing with or without an external medical review.
To make the request, call us or check “Yes” on the State Fair Hearing and External Medical Request Form where it says, “Do You Want Your Services to Continue?”.
If you lose your state fair hearing, you may have to pay your dental plan back for services provided to you during the fair hearing process. UnitedHealthcare Dental cannot ask you to pay them back for services you received without permission from HHSC.
What to Expect After You Request a State Fair Hearing
When you ask for a state fair hearing with or without an external medical review, a hearings officer will be placed in charge of your case.
You’ll get a Notice of Hearing in the mail within 10 calendar days of your request for a state fair hearing. It will tell you the date, time, and location of your hearing.
If you ask for an external medical review, it will happen before your state fair hearing. An external medical review doesn’t affect when your state fair hearing will be scheduled.
| About the External Medical Review |
|---|
|
| About the State Fair Hearing |
|---|
|
Emergency State Fair Hearings and External Medical Reviews
You can ask for an emergency state fair hearing if you feel your health will be seriously harmed by waiting for a decision. HHSC will review your case and determine if you qualify for an emergency state fair hearing. If your dentist supports your request, they should submit the support in writing to HHSC.
If you get an emergency state fair hearing, your hearing will be scheduled, and you will get a decision within three business days of your request.
If you request an emergency external medical review with your emergency state fair hearing, you’ll get the external medical review decision within two business days. You can choose whether you want to have the state fair hearing you requested.
Need Help?
You or your representative can call us at 1-877-901-7321 to learn more about a state fair hearing and an external medical review.
If you have more questions about the state fair hearing process, call an HHSC ombudsman at 866-566-8989 or complete the online form at hhs.texas.gov/managed-care-help