| (a) For appeals that relate to claims or other benefits,
the following procedures apply:
(1) A person enrolled in TRS-ActiveCare, other than
a person enrolled in a health maintenance organization (HMO) participating
in TRS-ActiveCare, who is denied payment of a claim or other benefit
("Claimant") may appeal the denial through a written request filed
with the administering firm in accordance with procedures established
by the administering firm.
(2) The final decision by the administering firm or
by any external review organization, whichever occurs later, shall
be the final decision on the appeal.
(b) For appeals that relate to claims or other benefits,
persons enrolled in an HMO under contract with TRS-ActiveCare shall
follow the appeal procedures set out by the HMO.
|
| Source Note: The provisions of this §41.50 adopted to be effective December 26, 2002, 27 TexReg 12004; amended to be effective October 27, 2003, 28 TexReg 9289; amended to be effective April 28, 2004, 29 TexReg 3969; amended to be effective August 25, 2004, 29 TexReg 8134; amended to be effective March 8, 2007, 32 TexReg 1092; amended to be effective March 25, 2008, 33 TexReg 2556; amended to be effective April 1, 2011, 36 TexReg 2001; amended to be effective September 1, 2011, 36 TexReg 5380; amended to be effective December 22, 2014, 39 TexReg 10029; amended to be effective August 15, 2019, 44 TexReg4189 |
