Understanding Appeal Rights for Denied Claims

Appeals Information Overview

• Claims for benefits may be denied for treatments, services, rescinded coverage, or limited eligibility.
• Denied claims come with a notice of the decision and inform about the right to appeal.

Right to Appeal an Adverse Determination

• Appeals can be filed if denial is due to medical necessity, experimental services, or denied prescription drugs/intravenous infusions.
• Appeals can be conducted by the claimant, their representative, or healthcare provider.
• A written appeal request must be filed within 180 calendar days of receiving the initial decision.
• Written appeals should be sent to:
  Blue Cross and Blue Shield of Texas
  Appeal Coordinator
  PO Box 660044
  Dallas, TX 75266-0044

Types of Appeals

• Standard Appeal:

  • Applicable for non-urgent issues, not involving emergency care or hospitalization.
  • Requests can be submitted before or after receiving care.
  • All submitted documentation and comments will be reviewed, even if already considered previously.

• Expedited Appeal:

  • Available for emergency care, life-threatening conditions, and currently prescribed medications or intravenous infusions.
  • Also applicable for denied step therapy protocol exceptions.

• Specialty Appeal:

  • Must be requested by the provider of record within 10 working days after denial.

• Acquired Brain Injury Appeal:

  • Specifically for appeals regarding services denied due to acquired brain injury.
  • These appeals must be completed within three working days of the request, followed by a written decision within 30 calendar days.

Standard Appeal Process

• Standard Appeals can be submitted in writing or by phone.
• Include any additional documentation or information relevant to the appeal.
• All comments, documentation, and medical records from you or your representative will be considered in the review process.