Member Complaints

If you have a complaint about your Harbor Health plan, we encourage you to contact our Member Services Department at the telephone number on the back of your ID Card. Our representatives are trained to address your concern and answer any questions you may have.

If the representative cannot resolve your issue over the phone, you are entitled to file a formal complaint with us. A complaint includes, but is not limited to, the following topics:

• Accessibility/Availability of medical services
• Balance billing from a network provider
• Claim or pre-authorization denial for the following reasons: not a covered benefit, benefit exclusion or benefit limits exhausted
• Enrollment issues
• Marketing
• Member Services
• Network provider unavailability
• Quality of care from a network provider
• Reimbursement amounts

How to Initiate a Formal Complaint

To initiate a formal complaint, you must download the Member Complaint Form, fill it out and mail it to the address listed in the form. Within five business days from receipt of the written Member Complaint Form, we will send you a letter acknowledging the date we received your complaint. The total time for acknowledgement, investigation and resolution of the complaint, including a response letter, will not exceed 30 calendar days after we receive the written Member Complaint Form.

Complaints concerning an emergency or denials of continued hospitalization will be investigated and resolved in accordance with the medical immediacy of the case and will not exceed one business day from receipt of the complaint.

Filing Complaints with the Texas Department of Insurance

Any Member, including Members who have attempted to resolve complaints through our complaint system process and who are dissatisfied with the resolution, may file a complaint with the Texas Department of Insurance ("TDI") at:

Members may call TDI at 1-800-252-3439.

You may also file a complaint online at www.tdi.texas.gov or email TDI at ConsumerProtection@tdi.texas.gov.

The Commissioner of Insurance will investigate a complaint against us to determine our compliance with insurance laws within 60 days after the Department receives your complaint and all information necessary for the Department to determine compliance. The Commissioner may extend the time necessary to complete an investigation in the event any of the following circumstances occur:

• Additional information is needed.
• An on-site review is necessary.
• We, the Physician or Provider, or you do not provide all documentation necessary to complete the investigation.
• Other circumstances beyond the control of the Department occur.