| (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.
|
| Source Note: The provisions of this §81.9 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective December 31, 2003, 28 TexReg 11612; amended to be effective May 3, 2006, 31 TexReg 3588; amended to be effective December 31, 2007, 32 TexReg 10053; amended to be effective March 15, 2010, 35 TexReg 2202; amended to be effective June 12, 2012, 37 TexReg 4252; amended to be effective September 5, 2016, 41 TexReg 6754; amended to be effective March 27, 2018, 43 TexReg 1876 |
