Physician/Provider Information & Advice for Physicians and Providers

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Where to File Medicare, Medicaid and Other Health Plan Complaints

The Children's Health Insurance Program (CHIP)
All complaints involving CHIP should be directed to the Texas Department of Insurance, HMO Quality Assurance Section, Mail Code 103-6A, P. O. Box 149104, Austin, TX 78714-9104.

Government Employees

• Federal Employees (includes Postal Workers)
  

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

  U S Office of Personnel Management Agency Employee Review Retirement and Insurance Group P O Box 436 Washington DC 20044 Phone: 202-606-0777

• 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 should be directed to:

  Employee Retirement System Group Health Coverage P. O. Box 13207 Austin, Texas 78711 Phone: 512-476-6431

  State of Texas employees who have elected HMO coverage may file complaints with the Texas Department of Insurance, HMO Quality Assurance Section, Mail Code 103-6A, P. O. Box 149104, Austin, TX 78714-9104.

• TASB (Texas Association of School Boards) Coverage
  

  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:

  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 (CHAMPUS)
  

  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 Foundation Health Federal Services, Inc. Therefore, we suggest that you send your complaint or appeal to:

  Foundation Health Federal Services, Inc. P O Box 8958 Madison WI 53708 Phone: 1-800-406-2832 (families and sponsors) 1-800-406-2833 (providers)

• 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 Phone: 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 Office of Health Affairs Attn: Robert Molloy, Director 702 Colorado Street, Suite 630 Austin, TX 78701 Phone: (512) 499-4616 Fax: (512) 499-4620

• Other Governmental Employees (county, city, and school districts)
  Local governments and political subdivisions are authorized to establish risk pools under Chapter 172 of 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 you contact either the Texas Department of Health or National Heritage Insurance Company to file an appeal or grievance. You may contact the Texas Department of Health at:

Texas Department of Health Bureau of Medicaid Appeals 1100 W 49th St Austin TX 78756-3172 Phone: 800-252-8263

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 TrailBlazer Health Enterprises. We suggest that you contact TrailBlazer Health Enterprises at:

TrailBlazer Health Enterprises Medicare Part B Correspondence P O Box 660156 Dallas TX 75266-0156 Phone: 1-800-442-2620 Web Site: http://www.trailblazerhealth.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
200 Constitution Ave.
NW Room N-5619
Washington DC 20210
Phone: (202) 219-8776

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

For more information contact: ConsumerProtection@tdi.state.tx.us