Texas Medicaid Denied? How to Appeal Through HHSC and STAR

Texas has one of the most restrictive Medicaid programs in the United States. The state did not expand Medicaid under the Affordable Care Act, meaning income-based eligibility thresholds are very low — leaving millions of low-income Texans without coverage. But if you are enrolled in Texas Medicaid, either through STAR, STAR+PLUS, STAR Health, or CHIP, and your claim or Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization was denied, you have the right to appeal.

How Texas Medicaid Is Organized

Texas Medicaid is administered by the Texas Health and Human Services Commission (HHSC). Most enrollees receive care through a managed care organization (MCO) under the STAR program. Common MCOs include:

• UnitedHealthcare Community Plan
• Molina Healthcare of Texas
• Amerigroup (Elevance Health)
• Community First Health Plans
• Superior HealthPlan (Centene)

Children may also be enrolled in CHIP (Children's Health Insurance Program), which has its own grievance process. Adults with disabilities or long-term care needs are often enrolled in STAR+PLUS, which covers both physical health and long-term services and supports.

Common Reasons Texas Medicaid Claims Are Denied

Texas Medicaid MCOs routinely deny claims for:

• Lack of medical necessity: The MCO decides the requested service doesn't meet its clinical criteria
• Prior authorization not obtained: The provider didn't get advance approval for a covered service
• Out-of-network service: Care was received from a provider outside the MCO's network
• Documentation deficiencies: The provider's records were incomplete or not submitted
• Benefit not covered: The service falls outside Texas Medicaid's benefit package (which is more limited than many states)
• Eligibility issues: A lapse in certification or a data error at HHSC

Texas Medicaid does not cover most adults without dependent children and has strict income limits. If your denial is based on eligibility, you can appeal that determination separately through HHSC.

Step 1 — File a Grievance or Appeal With Your MCO

Each Texas Medicaid MCO has an internal appeals process. When you receive a denial, you should receive an Adverse Action Notice (AAN) explaining:

• The reason for the denial
• Your right to appeal
• The deadline to appeal (usually 30–90 days depending on the MCO and type of denial)

Submit your appeal in writing. Include your doctor's clinical records, letters of medical necessity, and any peer-reviewed literature supporting your treatment. For urgent medical situations, request an expedited appeal, which must be resolved within 72 hours.

Step 2 — Request a State Fair Hearing Through HHSC

If your MCO denies your internal appeal, or if you want to escalate the dispute, you can request a State Fair Hearing with HHSC. This is a formal administrative hearing conducted by HHSC's Office of Hearings and Appeals.

To request a hearing, contact HHSC at:

• 1-800-252-8263 (Texas Medicaid & Healthcare Partnership)
• In writing to the HHSC State Office of Administrative Hearings

You must request a hearing within 90 days of the Adverse Action Notice. If you file within 10 days and your benefits were being reduced or discontinued, you can request continuation of benefits (aid paid continuing) pending the hearing outcome.

At the hearing, an impartial hearings officer reviews the evidence. You may bring a representative, including an advocate or attorney. The officer issues a written decision, which HHSC must implement.

Step 3 — Escalate to External Independent Review: Complete Guide" class="auto-link">External Review

Texas MCOs participating in Medicaid are subject to external independent review in some circumstances. You can also file a complaint with HHSC's Medicaid Managed Care Compliance unit if you believe your MCO failed to follow proper procedures.

For CHIP disputes, the process is similar but runs through the CHIP program's specific grievance channels. CHIP members have the same right to a state fair hearing.

Special Situations in Texas

STAR+PLUS waiver services: If your long-term services — such as personal attendant services, adult day care, or home modifications — were denied or reduced, request a fair hearing immediately. Loss of these services can be devastating, and aid paid continuing applies.

No Medicaid expansion: If you were told you don't qualify for Texas Medicaid because your income is too high (or because you don't fit an eligibility category), this is a policy limitation — not a denial you can appeal. If you believe the eligibility determination was made in error, however, you can appeal the eligibility decision itself.

EPSDT for children: Children under 21 enrolled in Texas Medicaid (STAR or STAR Health) are entitled to EPSDT services. If a medically necessary service for your child was denied because it's not in the standard benefit package, cite EPSDT in your appeal.

Fight Back With ClaimBack

Texas Medicaid appeals require precise documentation, tight deadlines, and knowledge of MCO-specific procedures. ClaimBack helps you build a strong appeal letter in minutes using your denial notice and medical records.

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Related Reading

• Common Reasons Insurance Claims Are Denied
• What Is Medical Necessity?
• How to Write an Insurance Appeal Letter