Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter E - STANDARDS FOR MEDICAID MANAGED CARE
Section 353.415 - Member Complaint and Appeal Procedures
Current through Reg. 49, No. 38; September 20, 2024
(a) Managed care organizations (MCOs) must develop and maintain a system and process for taking, tracking, reviewing, and reporting member complaints and appeals.
(b) MCOs must establish and maintain internal procedures for the resolution of member complaints and appeals. The procedures must be in writing. The procedures must be detailed and specific regarding how complaints and appeals are to be taken, to whom complaints are referred, and by when a complaint must be resolved.
(c) MCOs must establish a procedure to assist members in understanding and using the MCO's internal complaint and appeal process. The member's complaint and appeal procedure must be:
(d) HHSC will review the MCO's complaint and appeals procedures to determine if they comply with HHSC's standards before HHSC approves use of the procedures. Reports containing complaint summaries must be submitted to HHSC in compliance with HHSC policy.
(e) HHSC retains the authority to make the final decision following HHSC's fair hearing process.
