34 Tex. Admin. Code § 81.9 - Grievance Procedures
(a) Grievance
procedures regarding the denial of claims by administering firms for
HealthSelect of Texas, Consumer Directed HealthSelect, State of Texas Vision
and the Dental Choice Plans are set forth in the Master Benefit Plan Documents
for those plans. Internal and external reviews of claims are subject to
applicable federal statutes and rules and §1551.356, of the Act.
(b) The review procedures for a participant
in an HMO, dental health maintenance organization or a Medicare Advantage Plan
who is denied payment of insurance benefits, or otherwise receives an adverse
decision, are set forth in the applicable plan documents. Those decisions are
not appealable to ERS.
(c)
Grievance procedures regarding the denial of a claim, denial of eligibility for
coverage other than dependent eligibility, or other adverse decisions by a
carrier or an administering firm for all GBP coverage other than those subject
to subsections (a) and (b) are set forth in this subsection. A participant must
request the carrier or administering firm to reconsider the denial or other
adverse decision prior to seeking grievance review by ERS. Any additional
documentation in support of the claim may be submitted to the carrier or
administering firm with the request for reconsideration. If the claim is again
denied, the claim, accompanied by all related documents and copies of
correspondence with the carrier or administering firm, may be submitted by the
participant to the executive director for review. A request for grievance
review must be filed with ERS by the participant in writing within 90 days from
the date the carrier or administering firm formally denies the claim, or
provides notice of other adverse decision, and mails notice of the denial and
grievance right of appeal to the participant.
(d) When the executive director reviews any
matter arising under this section, information available to ERS will be
considered. When the executive director completes the review and makes a
determination, all parties involved will be notified in writing of the
decision.
(e) To the extent allowed
by statute, appeals of ERS' determination will be conducted under the
provisions of Chapter 67 of this title (relating to Hearings on Disputed
Claims) and the Act. A notice of appeal must be in writing and filed with ERS
within 30 days from the date ERS' determination is served on the
participant.
(f) Matters initiated
or referred to ERS concerning misrepresentations or fraud are not subject to
grievance procedures under this rule.
Notes
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