Claim Determinations
When BCBSTX receives a properly submitted claim, it has authority and discretion under the Plan to interpret and determine benefits in accordance with the Plan provisions. BCBSTX will render an initial decision to pay or deny a claim within 30 days of receipt of the claim. If BCBSTX requires further information in order to process the claim, we will request it within that 30-day period.
You have the right to seek and obtain a full and fair review by BCBSTX of any determination of a claim, any determination of a request for preauthorization, or any other determination made by BCBSTX of your benefits under the Plan.
If a Claim Is Denied or Not Paid in Full
On occasion, BCBSTX may deny all or part of your claim. There are a number of reasons why this may happen. We suggest that you first read the Explanation of Benefits summary prepared by BCBSTX; then review this Benefit Booklet to see whether you understand the reason for the determination. If you have additional information that you believe could change the decision, send it to BCBSTX and request a review of the decision. Include your full name, group and subscriber numbers with the request.
If the claim is denied in whole or in part, you will receive a written notice from BCBSTX with the following information, if applicable:
• The reasons for denial;
• A reference to the health care plan provisions on which the denial is based;
• A description of additional information which may be necessary to complete the claim and an explanation of why such information is necessary; and
• An explanation of how you may have the claim reviewed by BCBSTX if you do not agree with the denial.
Right to Review Claim Determinations
If you believe BCBSTX incorrectly denied all or part of your benefits, you may have your claim reviewed.
BCBSTX will review its decision in accordance with the following procedure:
• Within 180 days after you receive notice of a denial or partial denial, write to BCBSTX’s Administrative Office. BCBSTX will need to know the reasons why you do not agree with the denial or partial denial. Send your request to:
Claim Review Section
Blue Cross and Blue Shield of Texas
P. O. Box 660044
Dallas, Texas 75266-0044
• You may also designate a representative to act for you in the review procedure. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about you except to your authorized representative.
• BCBSTX will honor telephone requests for information, however, such inquiries will not constitute a request for review.
• You and your authorized representative may ask to see relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of a denial or partial denial. BCBSTX will give you a written decision within 60 days after it receives your request for review.
• If you have any questions about the claims procedures or the review procedure, write to BCBSTX’s Administrative Office or call the toll-free Customer Service Helpline number shown in this Benefit Booklet or on your Identification Card.
• If you have a claim for benefits which is denied or ignored, in whole or in part, and your Plan is governed by the Employee Retirement Income Security Act (ERISA), you may file suit under 502 (a) of ERISA.
