SECTION 370.602. Member Complaints and Appeals

(a) CHIP member complaints and appeals are subject to disposition consistent with applicable federal and state laws, regulations and rules, including the Texas Insurance Code and Texas Department of Insurance (TDI) regulations.

(b) Any member, or a representative acting on behalf of the member, may file a complaint or appeal with their managed care organization (MCO) through the MCO's internal appeal and complaint system.

(c) Any person, including those dissatisfied with the MCO's resolution of a member complaint or appeal, may submit a complaint to report an alleged violation to TDI.

(d) Any member or a representative acting on behalf of the member may request an external review of the MCO's adverse benefit determination, to be conducted by an independent review organization, when:

(1) the MCO internal appeal and complaint system regarding the adverse benefit determination has been exhausted; and

(2) the member or representative acting on behalf of the member is dissatisfied with the MCO's resolution of the appeal of an adverse benefit determination.

Source Note: The provisions of this §370.602 adopted to be effective March 1, 2012, 37 TexReg 1301; amended to be effective February 10, 2021, 46 TexReg 907