Where to File Complaints

When payers fail to comply with federal or state regulations, and attempts to resolve the issue directly are unsuccessful, it may be necessary to file a formal complaint with the appropriate regulatory agency. The responsible agency depends on the type of health plan. For example, most commercial plans are self-insured and fall under federal jurisdiction, specifically the U.S. Department of Labor. A smaller portion of commercial plans are fully insured and regulated by the Texas Department of Insurance. Medicare and Medicare Advantage plans are overseen by Regional Administrators, while Medicaid Managed Care plans are regulated by Texas Health and Human Services. Before filing a complaint, be sure to confirm the plan type.

Commercial Plans

Fully-Insured:
Plans that are regulated by the Texas Department of Insurance (TDI) will have "TDI" or "DOI" printed on the front of the member's insurance card. The TDI provider website has instructions, tips, and FAQ's on prompt pay laws and online access for providers and consumers to file complaints against payers who violate provisions of Texas Prompt Pay laws. Only complaints for fully-insured plans may be filed with TDI. For more information on fully-insured an self-insured plans, visit our ERISA page

TDI:
Phone: 1-800-578-4677
Fax: (512) 475-1771
Help Line: 800-252-3439

Self-Insured:
Most commercial plans are self-insured and fall under the jurisdiction of ERISA. Complaints can be filed with the Employee Benefits Security Administration (EBSA) online or by contacting the Dallas Regional Office.

Dallas Regional Office
525 South Griffin St, Room 900
Dallas, Texas 75202
972-850-4500

For a self-insured plan offered by a school district, government, union, or church employer, follow the complaint procedures in the health plan's benefits booklet and other plan documents.

Traditional Medicare, Medicare Advantage, and Medicare Part D

For Medicare providers seeking assistance from CMS in resolving Medicare, Medicare Advantage (MA), and Part D claims issues, use the Medicare Advantage (MA) Provider Complaint Submission Form. The complaint form is a cover sheet that must be submitted to CMS in a password-protected file (use password: providercomplaint), along with the requested documentation as indicated on the form, to the CMS Drug and Health Plan Operations (DHPO) email MedicarePartCDQuestions@cms.hhs.gov. CMS will receive and process all MA inquiries and complaints from providers through this centralized email. This will replace the current process of contacting CMS’ regional offices for MA complaints and questions. Multiple complaints for the same plan may be bundled and sent in one email, however, a separate form needs to be completed for each patient. Additional information for other types of complaints can be found on the form.

For CMS to act upon cases submitted, the provider must:
• Include all information and documentation requested on the cover sheet.
• Refrain from providing additional documentation not listed on the cover sheet (such as medical records).
• Certify that an effort was made to resolve the issue with the MA plan before contacting CMS.

Medicaid (TMHP) and Medicaid Managed Care Plans

For contacts and other resources regarding these plans, consult How to Submit a Complaint. 

Traditional Medicaid (TMHP): (see provider manual - Provider Complaints):
TMHP providers must exhaust the administrative and appeals provider resolution process with TMHP before filing an appeal or complaint with HHSC. Providers can file complaints by calling the TMHP Contact Center at 1-800-925-9126 or by submitting a written complaint to:

       Texas Medicaid and Healthcare Partnership
       TMHP Complaints Resolution Department 
       PO Box 204270 
       Austin, TX 778720-4270
 
If appeals with TMHP have been exhausted, complaints may be sent to HHSC at:

      Texas Health and Human Services Commission
      HHSC Claims Administrator Contract Management
      PO Box 204077, Mail Code 91-X
      Austin, Texas 78720-4077
      Phone: (512) 249-3744