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).

If 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.