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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.
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.
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.
If you ever have an issue where you get denied for treatment or tests call the insurance company up and ask to speak with the "HIPAA Compliance/Privacy Officer" (by law they have to have one) Than ask for the NAMES as well as CREDENTIALS of every person accessing your record to make the decision of denial. (By law you have the RIGHT to that information) They will almost always REVERSE THE DECISION very shortly rather than admit that the committee is made of low paid HS graduates looking for "criteria words" making the medical decision to deny your case. Even in the rare case it is made by medical personnel. It is unlikely that it is made by a board-certified doctor in that specialty AND THEY DON'T WANT YOU TO KNOW THIS! Any refusal should be reported to US Office of Civil Rights (OCR.gov) as a HIPAA violation.
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!