Children's Health Insurance Program (CHIP)

We want you to be able to understand our health information. Here are ways we can make it easier: 

• Member materials are available in other languages. You can also get information in large print, Braille or audio files. These materials can be provided at no charge in 5 business days.
• Providers who speak different languages. Our provider directory will tell you which ones.
• Many of our Member Service Navigators speak several languages, too.
• Our interpreter service supports more than 240 languages over the phone, including American Sign Language.
• If you have trouble hearing or speaking over the phone, you can use a text telephone. It’s a free service. Call 711 to learn more. Use the number 1-866-785-1628 to get connected with us.

For help or to find out more, please contact Member Services.

Search online for a network provider

Search for a behavior health/mental health specialist

myUHC.com/CommunityPlan is your secure member website. See your covered benefits, claims, select a new PCP/PMP, view your plan documents, review your individual health record, get access to our extra programs, and much more.

Our UnitedHealthcare® app is available for use on your smartphone. Just search UnitedHealthcare in the App Store or Google Play to download. You can access your digital member ID card, review health benefits, access claims information, locate providers, and more.

Medical questions and situations come at inconvenient times. When you have questions about your health or your child's health, you can call a trained nurse at 1-800-850-1267, 24 hours a day, 7 days a week.

Our Nurse Hotline nurses will: 

• Listen to the symptoms.
• Guide you on self-care.
• Advise you about getting care at a doctor visit or an urgent care center.
• Suggest you go right to the emergency department.

For information on Disaster Assistance click here.

Prior Authorizations

• With respect to a member who is hospitalized at the time of the request UHC will issue a coverage determination within 1 business day. For members who are not hospitalized at the time of a routine prior authorization request, within 3 business days or up to 72 hours for expedited authorization requests.
• UHC will send a request for additional information if a decision cannot be made based on the information submitted within the initial request. The request will include a list of documents that are needed. For members under the age of 21, UMCM 3.22 is followed and the authorization decision can be pended for up to 7 days from the request date before a coverage determination will be issued to allow additional time for the necessary information to be submitted. 
• Our current prior authorization lists are broken out by when they went into effect and are located here.
  • UHC’s telephone, fax and provider portal link are listed at the top of each of our Prior Authorization documents so we can be easily contacted with any questions.
• Eligibility and benefits information on UHC’s website can be found here. 
  • Medicaid MCOs are responsible for providing all services and benefits available to clients of the Medicaid Fee-for-Service (FFS) Program to the MCO’s Medicaid Members, in the same amount, duration, and scope as is available through FFS as reflected in the state plan under Title XIX of the Social Security Act Medical Assistance Program and detailed in the Texas Medicaid Provider Procedures Manual (TMPPM).
    • Clinical prior authorization can be found in the TMPPM, which is located here.  
    • Members may also call into member services to clarify prior authorization requirements or obtain assistance with a request.
      • STAR+PLUS, STAR and CHIP: 1-888-887-9003
      • STAR Kids: 1-877-597-7799

Understanding your rights and responsibilities

The Texas Office of Consumer Credit Commission (OCCC) helps the public understand their rights and responsibilities. Find forms and additional information on their website. 

Complaint Procedures

You can send a complaint to us (the URA): Enrollees, individuals acting on behalf of enrollees, and health care providers may file a written or oral complaint about our utilization review process or procedures. Use the telephone numbers and address referenced above to file your oral or written complaint. We will respond to your complaint in writing within 30 days.

Complaints to TDI: A complainant also has the right to file a complaint with TDI by contacting TDI at the following address, telephone numbers, or website:

Texas Department of Insurance
PO Box 149091
Austin, TX 78714-9091

1-800-252-3439
Fax: 512-490-1007
Online: www.tdi.texas.gov

Complaints may be filed orally or through written correspondence. For oral complaints, members are requested to call member services at 888-887-9003. Written complaints may be mailed to:

UnitedHealthcare Community Plan Appeals and Grievances
P.O. Box 31364
Salt Lake City, UT 84131-0364

Should a member need assistance in filing a complaint, the health plan has member advocates available to assist the member. Member advocates may be reached by calling our customer service toll-free at 888-887-9003 and requesting to speak to a member advocate. Members may have a representative file their complaint for them.

If we deny the appeal (continue to deny the services or treatment described above), the enrollee or someone acting on the enrollee’s behalf and the provider of record have the right to request a review by MAXIMUS Federal External Review. MAXIMUS does not have an affiliation with your payor (insurance company or health plan), your health care providers, or the URA.

To request a MAXIMUS Federal External Review, fill out the enclosed MAXIMUS Federal External Review Request and return it to MAXIMUS Federal Services:

Mail: HHS Federal External Review Request
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

Email: FERP@maximus.com

Online: Submit a request online at: https://externalappeal.com/ferpportal/#/home

Select the link “Request a Review Online” in the heading.

Fax: 1-888-866-6190

Call: 1-888-866-6205; Monday - Friday 8:00 am – 5:00 pm EST

If you believe your situation is urgent, you may ask for an expedited (fast) review when emailing, faxing or by calling the Federal Review Process at 1-888-866-6205 ext. 3326. If submitting the review request online select “expedited”.

The patient, parent, or the patient’s legal guardian must sign the consent to release medical information to MAXIMUS (included as part of the review request form). 

It’s important to get medical care when you need it. Call your doctor’s office to make an appointment. Tell them the reason for the visit. This will help them make the appointment within the right time frame.

Member rights

1. You have the right to get accurate, easy-to-understand information to help you make good choices about your child’s health plan, doctors, hospitals and other providers.

2. Your health plan must tell you if they use a “limited provider network.” This is a group of doctors and other providers who only refer patients to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses “limited networks,” you should check to see that your child’s PCP and any specialist doctor that you might like to see are part of the same “limited network.”

3. You have the right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know about what those payments are and how they work.

4. You have a right to know how the health plan decides whether a service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.

5. You have a right to know the names of the hospitals and other providers in your health plan and their addresses.

6. You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it.

7. If a doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child’s PCP. Ask your health plan about this.

8. Children who are diagnosed with special health care needs or a disability have the right to special care.

9. If your child has special medical problems, and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months, and the health plan must continue paying for those services. Ask your plan about how this works.

10. Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her Primary Care Provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral.

11. Your child has the right to emergency services if you reasonably believe your child’s life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a copayment depending on your income.

12. You have the right and responsibility to take part in all the choices about your child’s health care.

13. You have the right to speak for your child in all treatment choices.

14. You have the right to get a second opinion from another doctor in your health plan about what kind of treatment your child needs.

15. You have the right to be treated fairly by your health plan, doctors, hospitals and other providers.

16. You have the right to talk to your child’s doctors and other providers in private, and to have your child’s medical records kept private. You have the right to look over and copy your child’s medical records and to ask for changes to those records.

17. You have the right to a fair and quick process for solving problems with your health plan and the plan’s doctors, hospitals and others who provide services to your child. If your health plan says it will not pay for a covered service or benefit that your child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.

18. You have a right to know that doctors, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

19. You have a right to know that you are only responsible for paying allowable copayments for covered services. Doctors, hospitals, and others cannot require you to pay any other amounts for covered services.

20. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:

a. Be treated fairly and with respect.

b.  Know that your medical records and discussions with your providers will be kept private and confidential.

21. You have the right to use each complaint and appeal process available through the managed care organization and through CHIP.

22. You have a right to make recommendations to your health plan’s member rights and responsibilities.

Member responsibilities

You and your health plan both have an interest in seeing your child’s health improve. You can help by assuming these responsibilities.

1. You must try to follow healthy habits. Encourage your child to stay away from tobacco and to eat a healthy diet.

2. You must become involved in the doctor’s decisions about your child’s treatments.

3. You must work together with your health plan’s doctors and other providers to pick treatments for your child that you have all agreed upon.

4. If you have a disagreement with your health plan, you must try first to resolve it using the health plan’s complaint process.

5. You must learn about what your health plan does and does not cover. Read your Member Handbook to understand how the rules work.

6. If you make an appointment for your child, you must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and cancel it.

7. If your child has CHIP, you are responsible for paying your doctor and other providers copayments that you owe them.

8. You must report misuse of CHIP services by health care providers, other members, or health plans.

9. You must talk to your provider about your medications that are prescribed.

10. You must share information about your health with your Primary Care Provider and learn about service and treatment options. That includes the responsibility to:

a. Tell your Primary Care Provider about your health.

b.  Talk to your providers about your health care needs and ask questions about the

different ways your health care problems can be treated.

c. Help your providers get your medical records.

d. Must follow agreed upon plans and instructions for care.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr. If you have questions, please call Member Services at 1-888-887-9003, TDD/TTY: 7-1-1

Complaints and appeals

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

We want to help. If you have a complaint, please call us toll-free at 1-888-887-9003 to tell us about your problem. A UnitedHealthcare Community Plan Member Services Advocate can help you file a complaint. Just call 1-888-887-9003. Most of the time, we can help you right away, or at the most within a few days.

Once you have gone through the UnitedHealthcare Community Plan complaint process, you can complain to the Texas Department of Insurance (TDI) by calling toll-free1-800-252-3439, 8:00 a.m.–5:00 p.m., Monday–Friday.

If you would like to make your complaint in writing, please send it to the following address:

Texas Department of Insurance

Consumer Protection

P.O. Box 149091

Austin, Texas 78714-9091

If you can get on the Internet, you can submit your complaint at hhs.texas.gov/managed-care-help.

Can someone from UnitedHealthcare Community Plan help me file a complaint?

Yes, a UnitedHealthcare Community Plan Member Services representative can help you file a complaint, just call 1-888-887-9003. Most of the time, we can help you right away, or at the most within a few days.

How long will it take to process my complaint?

Most of the time, we can help you right away, or at the most within a few days. You will get a response letter within 30 days from when your complaint got to UnitedHealthcare Community Plan.

What are the requirements and time frames for filing a complaint?

There is no time limit on filing a complaint with UnitedHealthcare Community Plan. UnitedHealthcare Community Plan will send you a response letter telling you what we did about your complaint.

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

If you make a complaint for you/your child and it is not worked out the way you thought it should, you have the right to appeal. When you appeal, you will get information about having your concern heard by a Complaint Appeal Panel. This panel is made up of doctors, other providers, and UnitedHealthcare Community Plan members.

What is a specialty review?

A specialty review is a review where a provider who specializes in the type of care your child’s provider asked for will look at your child’s case. Your child’s provider can ask for this either:

• As part of your appeal after our first letter saying we won’t pay for all or part of the requested care. Your child’s provider must ask for this within 10 business days from the date we receive your appeal request.

• If your appeal is denied and a specialty review was not requested with the appeal. Your child’s provider can ask for a specialty review within 10 business days of the date of the appeal denial letter.

When we receive the specialty review request, we’ll send you a letter within 5 business days. This letter will let you know we got the specialty review request. We’ll send you a decision letter within 15 business days of when we received the request. This letter is our final decision. If you don’t agree with our decision, you may ask for an independent external review.

Where can I mail a complaint?

For written complaints, please send your letter to UnitedHealthcare Community Plan. Your letter must state your name, your member ID number, your telephone number and address, and the reason for your complaint. Please send your letter to:

UnitedHealthcare Community Plan 

Attn: Complaint and Appeals Department 

P.O. Box 31364 

Salt Lake City, UT 84131-0364

What can I do if my child’s doctor asks for a service for my child that is covered but UnitedHealthcare Community Plan denies or limits it?

UnitedHealthcare Community Plan will send you a letter if a covered service requested by your child’s PCP is denied, delayed, limited or stopped. If you are not happy with the decision, you can call Member Services at 1-888-887-9003 and ask for an appeal. We will record your verbal request. Your recording will then be made into a written request. We will send a form to you to complete, sign and return as soon as possible.

How will I find out if services are denied?

UnitedHealthcare Community Plan will send you a letter if a covered service requested by  your child’s PCP is denied, delayed, limited or stopped.

What are the time frames for the appeal process?

UnitedHealthcare Community Plan has up to 30 calendar days to decide if your request for care is medically needed and covered. We will send you a letter of our decision within 30 days. In some cases, you have the right to a decision within one business day. If your provider requests, we must give you a quick decision. You can get a quick decision if your health or ability to function could be seriously hurt by waiting. You also have the right to choose a quick review from an Independent Review Organization (IRO).

When do I have the right to request an appeal?

You may request an appeal whenever you do not agree with UnitedHealthcare Community Plan’s decision to deny services or care for you/your child.

Does my request have to be in writing?

Your request does not have to be in writing. If you would like to send in a written appeal you can mail written requests to:

UnitedHealthcare Community Plan

Attn: Complaint and Appeals Department

P.O. Box 31364

Salt Lake City, UT 84131-0364

No retaliation is allowed

UnitedHealthcare Community Plan will not punish a member, doctor or provider for filing a complaint against UnitedHealthcare Community Plan.

Can someone from UnitedHealthcare Community Plan help me file an appeal?

Member Services is available to help you file an appeal. You can ask them to help you when you call 1-888-887-9003.

What is an expedited appeal?

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.

How do I ask for an expedited appeal?

You may 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 child’s health could be hurt by waiting for a standard decision.”

To request a quick decision by phone, call UnitedHealthcare Community Plan Member Services at 1-888-887-9003.

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

We can record your verbal request. Your request will then be made into a written request.  If you would like to mail in your appeal request you can mail written requests to:

UnitedHealthcare Community Plan 

Attn: Complaint and Appeals Department 

P.O. Box 31364 

Salt Lake City, UT 84131-0364

What are the time frames for an expedited appeal?

UnitedHealthcare Community Plan must decide this type of appeal in one working day from the time we get the information and request.

What happens if UnitedHealthcare Community Plan denies the request for an expedited appeal?

If UnitedHealthcare Community Plan denies an expedited appeal, the appeal is processed through the normal appeal process, which will be resolved within 30 days. You will receive a letter explaining why and what other choices you may have.

Who can help me in filing an appeal or an expedited appeal?

If you/your child is in the hospital, ask someone to help you mail or call in your request for this type of appeal. You may also call UnitedHealthcare Community Plan Member Services at 1-888-887-9003 and ask someone to help you start an appeal or ask your/your child’s doctor to do it for you.

What is an Independent Review Organization (IRO)?

An Independent Review Organization (IRO) is an outside organization that reviews your health plan’s denial of a service you and your doctor feel is medically necessary. This organization is not related to your doctor or your health plan. There is no cost to you for this independent review.

You can ask for a review by an IRO after you complete the appeal process. An IRO is the final level of appeal for an Adverse Determination.

How do I request an IRO?

If you choose an IRO, you may contact UnitedHealthcare Community Plan Member Services at 1-888-887-9003.

What are the time frames for this process?

When UnitedHealthcare Community Plan gets your request, we send it to the IRO within 5 calendar days. We work with the IRO to give them all the information about your case. The IRO will let UnitedHealthcare Community and YOU know what they decide. This decision is final and UnitedHealthcare Community Plan will work with you and your child’s providers to do what the IRO says must be done.