Complaints and Appeals

Click one of the questions below to display our recommendation.

An appeal is the process you or someone acting on your behalf can request when you do not agree with the health plan's action and you want a review. This may be a denial or limited authorization of a requested service. You can find the appeals process on page 53 within the CHIP Member Handbook.

You may ask Cook Children's Health Plan for another review of this decision. This is called an "appeal." You can call Member Services and ask for an appeal.

If services are denied, we will send your provider a letter telling them why the service was denied. A copy of the letter will also be sent to you. You may also call us at 1-800-964-2247 to ask for status of your appeal.

We will send you a letter within five working days to let you know:

That we received your request for appeal.
If we need any more information in order to process the appeal.
If you called us to request an appeal, you will receive a letter that tells you send a signed request in writing back to Cook Children's Health Plan.
We will complete the appeal no later than 30 calendar days from the date you asked for the appeal.

You may also call us at 1-800-964-2247 to ask for status of your appeal.

You may request an appeal whenever you do not agree with our decision to deny services or care for you.

We can accept your request orally or in writing. Mail written requests to:

Cook Children’s Health Plan
Attn: Appeals P.O. Box 2488
Fort Worth, TX 76113-2488
Call us at 1-800-964-2247

Yes. Member Advocates are available to help you file an appeal. Once they help you file it, they will send you a letter and ask you or someone acting on your behalf to sign a form and send it back to Cook Children's Health Plan. Please call 1-800-964-2247 to reach a Member Advocate today.

An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

You can ask for this type of appeal in writing or by phone. Make sure you write "I want a quick decision or an expedited appeal," or "I feel my/my child's health could be hurt by waiting for a standard decision." To request a quick decision by phone, call Member Services. Call Member services at 1-800-964-2247.

We can accept your request orally or in writing. Mail written requests to:

Cook Children's Health Plan
Attn: Appeals
PO Box 2488
Fort Worth, TX 76113-2488

If we deny an expedited appeal, it will be resolved within 30 days. You will get a letter telling you why and what other choices you may have.

We have one working day from the time we get the information and appeal request.

Member Services will help you. Call Member services at 1-800-964-2247.

Call Service Coordination at 1-800-964-2247. We will send you a letter if we deny a service because it is not medically necessary. The letter will include a form you can fill out to ask for an IRO.

If it is not a life-threatening condition, no later than the earlier of the:

15th day after the date the IRO gets all the information they need to make their decision; or
20th day after the date the IRO gets the request for a review.

If it is a life-threatening condition, no later than the earlier of the:

5th day after the date the IRO gets all the information they need to make their decision; or
8th day after the date the IRO gets the request for a review.

Filing a Complaint

We want to help. If you have a complaint, please call us toll-free at 1-800-964-2247 to tell us about your problem. A Cook Children's Health Plan Member Services advocate can help you file a complaint. Most of the time we can help you right away or within a few days. You can also find the process of filing a complaint on page 52 within the CHIP Member Handbook.

For written complaints, please send your letter to Cook Children's Health Plan. Your letter must state your name, your Member ID number, your phone number and address and the reason for your complaint.

Please send your letter to:

Cook Children's Health Plan
Attention: Complaints and Appeals
P.O. Box 2488
Fort Worth, TX 76113-2488

We can accept your request orally if you call us at 1-800-964-2247.

There is no time limit on filing a complaint with Cook Children's Health Plan. We will send you a response letter telling you what we did about your complaint.

Most of the time we can help you right away or within a few days. You will get a response letter within 30 days from when your complaint was received by Cook Children's Health Plan.

Yes. Member Services can help you file a complaint. Call us at 1-800-964-2247.

Yes. You have the right to appear in-person before the CAP or send a written appeal to the CAP.

If you are not satisfied with the answer to your complaint, you can notify the Texas Department of Insurance by calling 1-800-252-3439.

If you would like to make your request in writing, send it to:

Texas Department of Insurance,
Attention: Consumer Protection
P.O. Box 149091
Austin, TX 78714-9091

To submit your complaint online, visit the Texas Department of Insurance.

For questions about your complaint or appeal or to get the status of your complaint or appeal, please call Member Services at 1-800-964-2247.

Complaints and Appeals

What is an appeal?

What can I do if my doctor asks for a service or medicine for me that's covered, but Cook Children's Health Plan denies or limits it?

How will I find out if services are denied?

What are the timeframes for the appeal process?

When do I have the right to request an appeal?

Does my request have to be in writing?

Can someone from Cook Children's Health Plan help me file an appeal?

What is an expedited appeal?

How do I ask for an expedited appeal?

Does my request for an expedited appeal have to be in writing?

What happens if Cook Children's Health Plan denies the request for an expedited appeal?

What are the timeframes for an expedited appeal?

Who can help me in filing an expedited appeal?

How do I ask for a review by an Independent Review Organization (IRO)?

What are the timeframes for this process?

Filing a Complaint

What should I do if I have a complaint? Who do I call?

Where can I mail a complaint?

Does my request for filing a complaint have to be in writing?

What are the requirements and timeframes for filing a complaint?

How long will it take to process my complaint?

Can someone from Cook Children's Health Plan help me file a complaint?

Do I have the right to meet with a Complaint Appeal Panel (CAP)?

If I am not satisfied with the outcome, who else can I contact?