PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.
PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.
PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.
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If the complaint is received verbally, PCHP will send a verbal complaint form documenting the verbal<br />
complaint. Once the Provider has reviewed and agrees with this documentation, the provider will return the<br />
verbal complaint form to PCHP. PCHP must receive the written complaint for the resolution process to<br />
continue.<br />
Within five (5) business days of receipt of a complaint by a provider, PCHP will send written acknowledgement<br />
of receipt of the complaint. This acknowledgement letter will indicate a description of the complaint process<br />
and the thirty (30) calendar day time frame for resolution of the complaint.<br />
Once the complaint has been resolved, PCHP will send a response letter to the provider with the resolution of<br />
the complaint, including the process to appeal the complaint when the provider is not satisfied with the PCHP<br />
decision.<br />
Provider Appeal Process to HMO<br />
In the event that the complaint is not resolved to the satisfaction of the provider, the provider can ask for an<br />
appeal to the address noted.<br />
- If the appeal is received verbally, PCHP will send a verbal appeal form documenting the verbal appeal.<br />
Once the provider has reviewed and agrees with this documentation, the provider will return the verbal<br />
complaint/appeal form to PCHP for processing. “If the form is not returned by the Provider, <strong>Parkland</strong> will<br />
continue to research to resolve the complaint PCHP will send a written acknowledgement letter within five<br />
(5) business days of receipt of the written request for an appeal of the complaint decision. This<br />
acknowledgement letter will indicate that PCHP has thirty (30) calendar days to process and respond to the<br />
appeal. PCHP will send a resolution letter indicating the final determination and criteria used to reach the<br />
final decision and notice of the provider’s right to file a complaint with the Texas Department of Insurance<br />
(TDI).<br />
Provider Complaint Process to the State<br />
A provider who believes that they did not receive full due process from PCHP can file a complaint with TDI by<br />
calling toll free 1-800-252-3439 or in writing at:<br />
53<br />
Texas Department of Insurance<br />
PO Box 149104<br />
Austin, Texas 78714-9104<br />
The network provider understands and agrees that HHSC reserves the right and retains the authority to make<br />
reasonable inquiry and to conduct investigations into provider and member complaints.<br />
CHIP Member Complaints/Appeal Process<br />
Member Complaints to HMO<br />
Definition of a “Complaint” - Any dissatisfaction expressed by a Complainant, orally or in writing to PCHP,<br />
with any aspect of <strong>Parkland</strong> <strong>Community</strong> <strong>Health</strong> <strong>Plan</strong>’s operations, including, but not limited to, dissatisfaction<br />
with plan administration, procedure related to review or Appeal of an Adverse Determination, as defined in<br />
Texas Insurance Code, Chapter 843, Subchapter G; the denial, reduction, or termination of a service for reasons<br />
not related to medical necessity; the way a service is provided; or disenrollment decisions. A complaint is not<br />
related to misinformation that is resolved promptly by supplying the appropriate information or clearing up the<br />
misunderstanding to the satisfaction of the PCHP member.