Member Appeals

The Tejas Utilization Management department may issue a denial for services requested for the following reasons:
  • Benefit eligibility
  • Insufficient information to determine medical necessity

Appeal Process

The Tejas enrollee, a person authorized to act on behalf of the enrollee, or the physician/provider may choose to file an appeal if requested services are denied, reduced, or terminated. Once a denial letter is issued, the general appeals process is as follows:

  • The enrollee, authorized person, or provider contacts Seton Health Plan CHIP verbally or in writing to appeal the denial decision.  The appropriate contact information will be included on the denial letter.
  • Seton Health Plan CHIP (Seton) will send an acknowledgement letter within five working days of receiving the appeal request.
  • Seton may take up to 30 days to process a standard appeal request.
  • An expedited appeal may be requested in cases where the enrollee's health could be seriously harmed by waiting for the standard 30 day process. A request for an expedited appeal must be specified clearly on the appeal request.  If Seton determines that the request qualifies for an expedited appeal, the request will be resolved within one business day of all necessary appeal information being received.
  • Denials for clinical reasons are also eligible for the Independent Review Organization process.  This may replace the appeal process in cases of life threatening conditions.  It is also the final step in the appeal process if the enrollee disagrees with the appeal decision of Seton.
  • At any time, the Texas Department of Insurance may be contacted regarding denials and appeals:

    Texas Department of Insurance
    P.O. Box 149104
    Austin, Texas 78714
    800-252-3439 (toll-free)