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RULE §67.5Appeals

(a) When the Executive Director denies a claim, or takes other action for which an appeal is allowed by law, the Participant or Member will be informed that he/she has 30 days from the date the determination letter is served on the Participant or Member to file a written notice of appeal as specified in §67.7 of this chapter (relating to filing and service of documents and Pleadings). The determination letter will inform the Participant or Member of this right, as appropriate. In order to facilitate a thorough and just adjudication of the appeal, the Participant or Member shall, upon request, sign and file with ERS a release authorizing the use and admission into evidence in the appeal of relevant information, which may also include confidential information and sensitive data. Mandatory venue for an administrative hearing of the appeal will be in Austin, Texas.

(b) The Executive Director shall decide whether or not a notice of appeal is timely filed under this chapter. ERS will only accept late appeals based on a showing of good cause by the Participant or Member. Failure of the Appellant to execute and file with ERS a proper release under subsection (a) of this section within 30 days after filing a Notice of Appeal may be grounds for ERS to dismiss the appeal as untimely. The Executive Director's decision in these matters constitutes final Agency action on the issue and no administrative appeal from the Executive Director's decision is available.

(c) Standing. Unless otherwise provided by law, standing to pursue an administrative appeal under this chapter is limited to Members, Participants, Insurers, Appellants, Appellees, Administering Firms, beneficiaries of a deceased Member or Participant, and Persons or Agencies permitted to intervene pursuant to §67.21 of this chapter (relating to intervention). Healthcare providers under the Texas Employees Group Benefits Act, ERS vendors (other than Insurers and Administering Firms) and other third parties not specifically designated herein as having standing do not have standing to appeal ERS decisions.

(d) In accordance with §815.511(d), Government Code and §1551.360, Insurance Code, the Board delegates its authority to determine all Proceedings within its jurisdiction to the Executive Director. In his/her discretion, the Executive Director may request the Board to decide a particular Proceeding when appropriate.

(e) The Executive Director may delegate, either generally, or in a particular Proceeding, the duties of the Executive Director under this chapter to another Person who is employed by ERS.

Source Note: The provisions of this §67.5 adopted to be effective March 19, 1986, 11 TexReg 1149; amended to be effective January 10, 1999, 24 TexReg 165; amended to be effective September 14, 2006, 31 TexReg 7359; amended to be effective December 24, 2015, 40 TexReg 9302

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