Can I ask for a State Fair Hearing?

If you, as a Member of the health plan, disagree with the health plan’s decision, you have the right to ask for a State Fair Hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the State Fair Hearing within 120 days of the date on the health plan’s letter with the decision. If you do not ask for the State Fair Hearing within 120 days, you may lose your right to a State Fair Hearing.

To ask for a State Fair Hearing, you or your representative should either send a letter to the health plan at

Community Health Choice Texas, Inc.
Medical Appeals Department-Medical Affairs
2636 South Loop West, Suite 125 Houston, TX 77054
Phone: 713.295.2294 or toll-free at 1.888.760.2600
Fax: 713.295.7033

Or call toll-free at 1.888.760.2600.

If you ask for a State Fair Hearing within 10 days from the time you get the hearing notice from the health plan, you have the right to keep getting any service the health plan denied, at least until the final hearing decision is made. If you do not request a State Fair Hearing within 10 days from the time you get the hearing notice, the service the health plan denied will be stopped.

If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most State Fair Hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.

Can I ask for an emergency State Fair Hearing?

If you believe that waiting for a State Fair Hearing will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you or your representative may ask for an emergency State Fair Hearing by writing or calling Community Health Choice. To qualify for an emergency State Fair Hearing through HHSC, you must first complete Community Health Choice’s internal appeals process.

If you, as a Member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical Provider may be your representative. If you want to challenge a decision made by Community Health Choice, you have the option to request only a State Fair Hearing Review no later than 120 Days after the Community Health choice mails the appeal decision notice. If you do not ask for the fair hearing within 120 days, you may lose your right to a fair hearing.

To ask for a fair hearing, you or your representative should send a letter to the health plan at:

Community Health Choice Texas, Inc.
Medical Affairs-Medical Appeals Department
2636 South Loop West, Suite 125
Houston, TX 77054
Phone: 713.295.2294 or toll-free at 1.888.760.2600
Fax: 713.295.7033

You may mail your Behavioral Health appeal to the address below:

Community Health Choice Texas, Inc.
Attention: Medical Affairs-BH Appeals
P.O. Box 1411
Houston, TX 77230
713.295.2294 or toll-free at 1.888.760.2600 or TTY 7-1-1
Fax: 713.576.0394/Attention: BH Appeals Coordinator

If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing from the State Representative. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied.

External Medical Review Information

Can a Member ask for an External Medical Review? If a Member, as a member of the health plan, disagrees with the health plan’s internal appeal decision, the Member has the right to ask for an External Medical Review. An External Medical Review is an optional, extra step the Member can take to get the case reviewed for free before the State Fair Hearing. The Member may name someone to represent him or her by writing a letter to the health plan telling Community Health Choice the name of the person the Member wants to represent him or her. A provider may be the Member’s representative. The Member or the Member’s representative must ask for the External Medical Review within 120 days of the date the health plan mails the letter with the internal appeal decision. If the Member does not ask for the External Medical Review within 120 days, the Member may lose his or her right to an External Medical Review.

To ask for an External Medical Review, the Member or the Member’s representative should either:

• Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to the Member Notice of MCO Internal Appeal Decision letter and mail or fax it to by using the address or fax number at the top of the form;
• Call the Community Health Choice at 713.295.2294 or toll-free at 1.888.760.2600;
• Email Community Health Choice at [email protected] or;
• Go in-person to a local HHSC office.

If the Member asks for an External Medical Review within 10 days from the time the Member gets the appeal decision from the health plan, the Member has the right to keep getting any service the health plan denied, at least until the final State Fair Hearing decision is made. If the Member does not request an External Medical Review within 10 days from the time the Member gets the appeal decision from the health plan, the service the health plan denied will be stopped.

The Member may withdraw the Member’s request for an External Medical Review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing the Member’s External Medical Review request. An Independent Review Organization is a third-party organization contracted by HHSC that conducts an External Medical Review during Member appeal processes related to Adverse Benefit Determinations based on functional necessity or medical necessity. An External Medical Review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.

Once the External Medical Review decision is received, the Member has the right to withdraw the State Fair Hearing request. If the Member continues with the State Fair Hearing, the Member can also request the Independent Review Organization be present at the State Fair Hearing.

If the Member continues with a State Fair Hearing and the State Fair Hearing decision is different from the Independent Review Organization decision, it is the State Fair Hearing decision that is final.

The Member can make both of these requests by contacting Community Health Choice at:

Community Health Choice Texas, Inc.
Medical Appeals Department-Medical Affairs
2636 South Loop West, Suite 125
Houston, TX 77054
Phone: 713.295.2294 or toll-free at 1.888.760.2600
Fax: 713.295.7033

or the HHSC Intake Team at [email protected].

Can I ask for an emergency External Medical Review?

If you believe that waiting for a standard External Medical Review will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you, your parent or your legally authorized representative may ask for an emergency External Medical Review and emergency State Fair Hearing by writing or calling Community Health Choice. To qualify for an emergency External Medical Review and emergency State Fair Hearing review through HHSC, you must first complete Community Health Choice’s internal appeals process.

MDCP/DBMD Escalation Help Line

What is the MDCP/DBMD escalation help line?

The MDCP/DBMD escalation help line assists people with Medicaid who get benefits through the Medically Dependent Children Program (MDCP) or the Deaf-Blind with Multiple Disabilities (DBMD) program. The escalation help line can help solve issues related to the STAR Kids managed care program. Help can include answering questions about State Fair Hearings and continuing services during the appeal process.

When should Members call the escalation help line?

Call when you have tried to get help but have not been able to get the help you need. If you don’t know who to call, you can call 1.844.999.9543 and they will work to connect you with the right people.

Is the escalation help line the same as the HHS Office of the Ombudsman?

No. The MDCP/DBMD Escalation Help Line is part of the Medicaid program. The Ombudsman offers an independent review of concerns and can be reached at 1.866.566.8989 or go on the Internet (hhs.texas.gov/managed-care-help). The MDCP/DBMD escalation help line is dedicated to individuals and families that receive benefits from the MDCP or DBMD program.

Who can call the help line?

You, your authorized representatives or your legal representative can call.

Can members call any time?

The escalation help line is available Monday through Friday from 8 a.m.– 8 p.m. After these hours, please leave a message and one of our trained on-call staff will call you back.