My Claim Has Been Denied, Now What?

When you or a family member visits a doctor it’s usually for routine care.  But, there may be a time when you or a family member needs medical care that involves ongoing doctor visits, out-patient care or a hospital stay.  The last thing you want to worry about is a denied claim. To know if a claim is denied you will find the details on your Explanation of Benefits (EOB).

Denied ClaimIf a claim is denied you have the right to submit an appeal. Anyone can submit an appeal, which is a way to have that decision reviewed. Here are some steps to help you get started.

  • Fill out the Claim Review Form.  
  • Mail it to Blue Cross and Blue Shield of Texas (BCBSTX) at the address provided.
  • Call Member Services (the phone number is on the back of your ID card) with questions about the appeal process and plan benefits available to you.

What if you can’t appeal?
You can have an authorized representative, doctor, facility or other health care practitioner submit an appeal for you. But you need to give written or verbal permission for someone else to submit your appeal, unless it’s an urgent care appeal.  

Also, keep in mind that there are different appeals that are reviewed by separate groups within BCBSTX.

  • A clinical appeal is asking to reverse a ruling for care or service that was denied because it wasn’t considered medically necessary, or if the services were considered experimental or cosmetic. This may be pre- or post-service. The review is carried out by a doctor.
  • A non-clinical appeal is filed when you want BCBSTX to reconsider a previous complaint or action. This relates to administrative health care services such as your membership, access, or claim payment. This review is performed by a non-medical appeal committee.
  • Urgent care or expedited appeals take place if you, an authorized representative or doctor feels that denial of services may seriously risk your health. The doctor or facility may ask for an expedited appeal by calling the number on the back of your ID card.
  • A provider appeal is made by your doctor or the facility that is delivering your care. Most often this is about the length of stay or treatment that was denied by BCBSTX. This appeal is something that you might want to discuss with your doctor.  The doctor/clinical peer review process takes 30 days and leads to a written notice of appeal status. This appeal should:
    • Be in writing or by phone.  The denial letter will come with instructions from BCBSTX outlining the appeal process. These instructions are also included on your EOB.
    • Include a routing form, claim information and any supporting medical or clinical records.

In most cases, we’ll send a notification within 5 business days after we’ve received your appeal. This is to inform you that it’s in review. After reviewing your appeal in detail, we’ll inform you of the outcome within 30 business days. Please note that this timeline and process can vary based on your case’s urgency and whether we may need more information from you.

Still have questions? Call us at 888-697-0683 or the number on the back of your member ID card.

  • My son is in residential treatment after a life changing trauma and BCBS has decided he does not need this level of care. The facility filed an appeal which was denied claiming “not medically necessary”. They did not talk to him or to anyone - just denied it. My sons life is at stake and we are caught between insurance claiming the facility and the facility blaming BCBS. Currently, I am being charged $500 per day and I will have to sell my home and car or file for bankruptcy to cover his care. I’ve been researching and trying to figure out a solution. I read the external appeal can take 45 days. My son said if he doesn’t get the help he will end up taking his life from the trauma and depression I need help NOW, please!

  • My new born has SCID and needs a bone marrow transplant. The Specialist that we are seeing in Dallas is obviously out of network. They wanted us to originally go to a small in network clinic because we have a PPOthrough for bcbs. And we are trying to see an endocrinologist call that our Allergan specialist doctor is wanting us to see you because the baby could be experiencing health and mental delays. We’ve been trying to get our visit to the doctor approved for the past two months now and I’ve gotten rid of my old letters and every day that goes, on because of the issues the baby is having should be developing permanent issues. It’s so disappointing that our healthcare system is like this when we actually need some thing we’re getting denied and nobody cares nobody can make the decision and pull the trigger and say yes this child obviously has an issue and needs to see the doctor I need to see one that can actually tell what’s going on and as experience. Why can we not just get the doctors visits that we need approved it’s not like we like going to the doctor we are otherwise a healthy family we are just trying to get our baby healthy and Blue Cross Blue Shield obviously does not care at all and they are probably just waiting it out so that they can make more money and it it’s not their child

    We would just like to get our doctors visits approved and not be told to go to a local clinic around our house when our baby has scid. There only been a couple thousand cases of this in the last 30 years. Why would a little doctors office around our house even be an option.

  • Dear BCBS:  I’ve been diagnosed with pneumonia, pleural effusion and a a partially collapsed lung. Both my internist and pulmonologist have ordered CT scans, which has been denied as not medically necessary by your agent Evicore.  Given the urgency of my condition, I may have to pay cash for the diagnostic. We pay thousands a year in premiums and the university that holds the policy insures a number if employees. Your rationing of health care and denial of an obviously needed diagnostic is unconscionable. It also violates several Texas statues including the Texas Deceptive Trade Practices Act. Not only will the university consider dropping your plan, we may be required to seek redress through legal process. Others similarly situated may take note.