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HHSC Complaints – 2021 Q3Top 5 ComplaintsComplaint CategoryProvider Treatment Inappropriate/IneffectiveDenial of ClaimBalance BillingCustomer Service - OtherAccess to In-Network Provider (non-PCP)Number of Complaints659585528268256Top 5 Complaints for MembersComplaint CategoryProvider Treatment Inappropriate/IneffectiveBalance BillingAccess to In-Network Provider (non-PCP)Customer Service - OtherAccess to Care - OtherNumber of Complaints657522251246218Top 5 Complaints for ProvidersComplaint CategoryDenial of ClaimAuthorization IssueClaims/Payment - OtherPayment DisputeDelays in Claims HandlingNumber of Complaints574645547411
Top 5 Complaints by Program per 10,000MembersProgramMMPMMPMMPMMPMMPSTAR PLUSSTAR PLUSSTAR PLUSSTAR PLUSSTAR PLUSSTAR KidsSTAR KidsSTAR KidsSTAR KidsSTAR KidsSTAR HealthSTAR HealthSTAR HealthSTAR HealthSTAR DentalComplaint CategoryBalance BillingProvider Treatment Inappropriate/IneffectiveAccess to Care - OtherValue-added Services IssuesCustomer Service - OtherProvider Treatment Inappropriate/IneffectiveDenial of ClaimCustomer Service - OtherHome HealthBalance BillingDenial of ClaimProvider Treatment Inappropriate/IneffectiveBalance BillingHome HealthAccess to Care - OtherProvider Treatment Inappropriate/IneffectiveDenial of ClaimAuthorization IssueCustomer Service - OtherAccess to PCPDenial of ClaimBalance BillingProvider Treatment Inappropriate/IneffectiveAccess to In-Network Provider (non-PCP)Access to Out-of-Network ProviderProvider Treatment Inappropriate/IneffectiveCustomer Service - OtherBalance BillingDenial of ClaimAuthorization .20.12.10.06.03.03Enrollment by ProgramProgramMMPTotal Average Monthly Membersfor 2021 Q339,671STAR PLUS535,877STAR Kids169,207STAR Health42,794STAR3,744,156Dental3,543,7192
Percentage of Complaints Substantiated –Ombudsman DataSubstantiated4%Unsubstantiated4%Unable toSubstantiate93%10%11%79%STAR Kids8%10%83%STAR MPSTAR PLUSPercentage of Complaints Confirmed – MCSand MCO Self-Reported DataUnable to DetermineProgramConfirmedNot ConfirmedMMP78%21%0%STAR PLUS63%35%2%STAR Kids73%26%1%STAR Health89%11%0%STAR64%32%4%Dental40%60%0%Complaint Volume by ringTexas Children'sDriscoll Children'sCHCBCBSAetnaParklandCook Children'sFirstCareEl Paso FirstCommunity FirstScott & WhiteDell Children'sTotal 368Percentage of .51%2.72%1.95%1.87%1.83%1.83%.97%.93%.91%.72%.16%3
Complaint Volume by DMODMOTotal ComplaintsDentaQuestMCNAUnited Dental142355Percentage of TotalComplaints78.02%19.23%2.75%Total Enrollment by MCOMCOSuperiorAmerigroupTexas Children'sUnitedCHCDriscoll Children'sMolinaParklandCook Children'sCommunity FirstAetnaFirstCareEl Paso FirstBCBSScott & WhiteCigna-HealthSpringDell Children'sPercentage of al Enrollment by DMODMODentaQuestMCNAUnited DentalPercentage of Enrollment56.33%38.95%4.73%4
Top 5 Complaints by MCO/DMO per 10,000MembersMCO/DMOComplaint CategoryRateAetnaBalance Billing2.63AetnaDenial of Claim1.09AetnaDelays in Claims Handling.54AetnaAccess to In-Network Provider (non-PCP).45AetnaAccess to Out-of-Network Provider.45AmerigroupQuality of Care - Other1.66AmerigroupAccess to Care - Other1.40AmerigroupBalance Billing1.09AmerigroupAccess to In-Network Provider (non-PCP).79AmerigroupDenial of Claim.66BCBSBalance Billing5.36BCBSAccess to PCP1.48BCBSAccess to In-Network Provider (non-PCP)1.29BCBSHome Health1.11BCBSAccess to Out-of-Network Provider1.11CHCDenial of Claim.935
MCO/DMOComplaint CategoryRateCHCBalance Billing.50CHCProvider Treatment Inappropriate/Ineffective.47CHCAccess to Out-of-Network Provider.22CHCAccess to In-Network Provider (non-PCP).22Cigna-HealthSpringProvider Treatment dded Services Issues3.43Cigna-HealthSpringService Coordination/Service Management3.23Cigna-HealthSpringMCO Staff Not Responding3.23Cigna-HealthSpringAuthorization Issue2.83Community FirstAccess to Care - Other.48Community FirstAccess to In-Network Provider (non-PCP).28Community FirstProvider Treatment Inappropriate/Ineffective.21Community FirstCustomer Service - Other.21Community FirstAuthorization Issue.21Cook Children'sProvider Treatment Inappropriate/Ineffective.90Cook Children'sDenial of Claim.76Cook Children'sCoordination of Care.55Cook Children'sAccess to Care - Other.5528.066
MCO/DMOComplaint CategoryRateCook Children'sCustomer Service - Other.41Dell Children'sAccess to Out-of-Network Provider.88Dell Children'sPrescription Services - Clinical Prior Authorization.29Dell Children'sDenial of Claim.29Dell Children'sBalance Billing.29Dell Children'sAccess to In-Network Provider (non-PCP).29DentaQuestProvider Treatment Inappropriate/Ineffective.19DentaQuestCustomer Service - Other.16DentaQuestBalance Billing.08DentaQuestDenial of Claim.04DentaQuestAuthorization Issue.04Driscoll Children'sDenial of Claim2.43Driscoll Children'sProvider Treatment Inappropriate/Ineffective1.45Driscoll Children'sDisagree with MCO Policy.89Driscoll Children'sCustomer Service - Other.89Driscoll Children'sAccess to Care - Other.51El Paso FirstBalance BillingEl Paso FirstMCO Customer Service/Staff Behavior3.74.757
MCO/DMOComplaint CategoryRateEl Paso FirstProvider Treatment Inappropriate/Ineffective.50El Paso FirstOther Insurance.25El Paso FirstAccess to Care - Other.12FirstCareDenial of ClaimFirstCareBalance Billing.76FirstCareProvider Treatment t - Other.33FirstCareAccess to Out-of-Network Provider.33MCNACustomer Service - Other.04MCNAProvider Treatment Inappropriate/Ineffective.03MCNADenial of Services.03MCNABalance Billing.02MCNAAccess to In-Network Provider (non-PCP).02MolinaProvider Treatment Inappropriate/Ineffective3.51MolinaDenial of Claim3.37MolinaBalance Billing2.65MolinaCustomer Service - Other2.45MolinaAccess to In-Network Provider (non-PCP)2.451.538
MCO/DMOComplaint CategoryRateParklandBalance Billing.73ParklandAccess to PCP.42ParklandAccess to Out-of-Network Provider.36ParklandAccess to In-Network Provider (non-PCP).36ParklandCorrespondence/ID Card.26Scott & WhiteDenial of ClaimScott & WhitePrescription Services - Other Insurance.94Scott & WhiteAccess to Out-of-Network Provider.75Scott & WhiteDisagree with MCO Policy.56Scott & WhiteAccess to In-Network Provider (non-PCP).38SuperiorProvider Treatment Inappropriate/Ineffective1.50SuperiorDenial of Claim1.33SuperiorCustomer Service - Other1.05SuperiorBalance Billing.94SuperiorAuthorization Issue.75Texas Children'sDenial of Claim.92Texas Children'sProvider Treatment Inappropriate/Ineffective.54Texas Children'sBalance Billing.501.319
MCO/DMOComplaint CategoryRateTexas Children'sPrescription Services - Other Insurance.44Texas Children'sAccess to In-Network Provider (non-PCP).29UnitedDenial of Claim2.90UnitedProvider Treatment Inappropriate/Ineffective2.70UnitedBalance Billing2.12UnitedValue-added Services Issues.81UnitedHome Health.81United DentalBalance Billing.18United DentalDenial of Claim.06United DentalAccess to In-Network Provider (non-PCP).0610
Percentage of Complaints Substantiated byMCO/DMO – Ombudsman gCommunity FirstCook Children'sDell Children'sDentaQuestDriscoll Children'sEl Paso FirstFirstCareMCNAMolinaParklandScott & WhiteSuperiorTexas Children'sUnitedUnited %20%18%25%0%0%7%16%8%0%11%11%10%0%Unable %64%77%70%100%80%75%78%100%Percentage of Complaints Confirmed byMCO/DMO – MCS and MCO Self-Reported gCommunity FirstCook Children'sDell Children'sDentaQuestDriscoll Children'sEl Paso FirstFirstCareMCNAMolinaParklandScott & WhiteSuperiorTexas 6%39%83%34%62%47%74%31%85%80%52%Not 19%41%14%17%47%Unable to %11
MCO/DMOUnited DentalConfirmed50%Not Confirmed50%Unable to Determine0%12
Overall Rate of Complaints per 10,000 Members byMCO and Community FirstCook Children'sDell Children'sDriscoll Children'sEl Paso FirstFirstCareMolinaParklandScott & WhiteSuperiorTexas Children'sUnitedOverall Rate2021 0.994.746.7612.445.0316.3110.972021 .293.234.8411.844.4412.059.932021 2.262.504.2712.956.5713.9311.70Overall Rate of Complaints per 10,000 Members byDMO and QuarterDMODentaQuestMCNAUnited DentalOverall Rate2021 Q3.71.25.30.512021 Q2.59.26.17.442021 Q1.86.32.50.6313
Top 5 Complaints by MCO/DMO per 10,000 Members MCO/DMO Complaint Category Rate Aetna Balance Billing 2.63 Aetna Denial of Claim 1.09 Aetna Delays in Claims Handling .54 Aetna Access to In-Network Provider (non-PCP) .45 Aetna Access to Out-of-Network Provider .45 Amerigroup Quality of Care - Other 1.66 Amerigroup Access to Care - Other 1.40
