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How to File Medical Claims Appeals

​Here’s What To Do if Your Claim is Denied

When you use your health care, there’s a possibility you can have a denied – or partially denied – claim. A partially denied claim means your medical administrator will only pay for part of your procedure, service or prescription.

This may never happen to you with your TRS health plan, but if it does, it’s good to understand the appeals process for a denied claim. The information found here can help you navigate the situation more easily.

The Basics

The appeals process for TRS-ActiveCare and TRS-Care Standard are different than TRS-Care Medicare Advantage.

Blue Cross and Blue Shield of Texas (BCBSTX) handles TRS-ActiveCare and TRS-Care Standard medical plans and appeals. TRS made sure these plans include referrals to an Independent Review Organization (IRO). This means doctors who are not affiliated with BCBSTX will review your appeal.

UnitedHealthcare handles the TRS-Care Medicare Advantage plan and medical appeals. However, this plan follows the appeal rules set by the Centers for Medicare & Medicaid Services (CMS). UnitedHealthcare and TRS must comply with CMS guidelines.

Below, we’ll walk you through the processes for each plan. If you see a word in bold, it’s defined in our Quick Glossary.

Remember, it's important to meet the deadlines throughout the process. Pay close attention to any deadlines or dates outlined in the communication(s) you get from your medical administrator.

TRS Support

TRS relies on the clinical knowledge of our vendors to make final decisions about medical claims. However, our TRS Health​ staff can guide members through the process and answer questions. Counselors are available at 1-888-237-6762, Mon. – Fri., 7 a.m. – 6 p.m. to provide support to those who file an appeal. Members can also email healthcarecomm@trs.texas.gov if they prefer email communication.

TRS-ActiveCare and TRS-Care Standard

TRS-ActiveCare and TRS-Care Standard have the Same Appeals Process.

Ask For a Benefits Determination First

The easiest way to avoid an appeal is to ask for a benefits determination from the facility or provider’s office before your medical service or procedure, especially if it’s expensive or complicated. Your provider will contact BCBSTX to determine if they’ll pay for a service or procedure before it happens.

If you need a service or procedure urgently, you can either ask BCBSTX for an urgent care claim review or submit an appeal after your claim is denied.

  • First benefits determinations can take up to 30 days.
  • Urgent claims approvals can take up to 72 hours.
  • Reviews of denials issued after a service or procedure can take up to 60 days.

If you need to make an appeal for a denied claim with BCBSTX for TRS-ActiveCare or TRS-Care Standard, there is a defined process to follow.

One internal review by a doctor at BCBSTX who was not involved in denying your claim is allowed per appeal. If BCBSTX denies the internal appeal, you can ask for an external review with an Independent Review Organization (IRO).

Here’s what happens during the internal appeals process:

  • You’ll receive a letter of explanation about why your claim was denied or partially denied. If you’d like to speak to a Personal Health Guide (PHG) about the denial, please contact BCBSTX at 1-866-355-5999.
  • If you want to dispute the denial, you have 180 days to do so. You do this by either calling a PHG at 1-866-355-5999 or sending it in writing to:
    • Claim Review Section
      Blue Cross and Blue Shield of Texas
      P.O. Box 660044
      Dallas, TX 75266-0044
  • You can represent yourself, or, in the case of an urgent care request, your provider can advocate on your behalf. You can also choose another authorized representative. If you want someone else to represent you, you’ll need to call a PHG at 1-866-355-5999 and request an Authorized Representative Form.
  • Now, you or your authorized representative can request to review any documents related to your case. You can also present supporting documents in your favor. Examples of supporting documents include updated lab results, secondary medical conditions, or additional related medical records.
  • Your appeal is reviewed by a doctor associated with BCBSTX but was not involved in the initial denial of your claim. The individuals who made the original decision will not conduct the appeal.
  • Once the internal review is complete, you, your authorized representative, or your provider will receive written notice of the decision.
  • If you need assistance with the internal claims or appeals processes, please contact a PHG with BCBSTX at 1-866-355-5999.

If BCBSTX denies your internal appeal, you can ask for an external review from an IRO. Here’s what to expect:

  • You have four months from the date of the notice that your first appeal was denied to request an external review. You can only request an external review after your initial appeal is denied. You can find the External Review Form in your Explanation of Benefits or call a PHG at 1-866-355-5999 to request one. You, your authorized representative or provider will submit the External Review Form to BCBSTX. Fax it to 972-907-1868 or mail it to:

    BCBSTX – External Review Request 
    PO Box 660044 
    Dallas, TX 75266-0044

  • After your request, BCBSTX has five business days to see if your appeal meets the criteria for external review.
  • After their review, BCBSTX will notify you within one business day about your eligibility or if more documentation is needed. The preliminary review criteria can be found in your Benefits Booklet (TRS-ActiveCare; TRS-Care Standard).
  • If your appeal isn’t eligible for external review, BCBSTX will provide the reasons it’s not eligible in the notice.
  • If your appeal is approved for external review, an accredited IRO will be assigned. The IRO will be unbiased and independent.
  • After the IRO is assigned, BCBSTX has five business days to provide the IRO the documents and other information used to make their denial determination.
  • The IRO must provide written notice of their decision within 45 days of receiving the request.
  • The IRO’s decision is considered final.

​If you still have questions about or need assistance with the appeal process, call a BCBSTX PHG at 1-866-355-5999, 24 hours a day, seven days a week.

The TRS Health can provide guidance but cannot get involved in the process. You can contact HIB customer service at 1-888-237-6762, Mon.–Fri., 7 a.m.–6 p.m.

TRS-Care Medicare Advantage

Ask for a Coverage Decision First

The easiest way to avoid an appeal is for you or your provider to call or write and ask UnitedHealthcare for a standard coverage decision before your medical service or procedure. This is good practice if your service or procedure will be more expensive or complex. You can also request a decision for Medicare Part B prescription drugs.

If it’s an urgent medical issue, you can ask for a fast coverage decision.

  • Standard coverage decisions can take up to 14 days.
  • Fast coverage decisions can take up to 72 hours.
  • Fast coverage decisions for prescription drugs are answered within 24 hours.

Request an Appeal

In some cases, UnitedHealthcare may decide your service is not covered or is no longer covered by Medicare. If you don’t agree with this decision, you can request an appeal.

TRS-Care Medicare Advantage appeals are made through UnitedHealthcare but are subject to Centers for Medicare & Medicaid Services (CMS) guidelines. Decisions are based on those guidelines, even when an Independent Review Organization (IRO) conducts the review.

There are five levels of appeals you can go through. Additional details about the appeals process can be found in your TRS-Care Medicare Advantage Benefits Booklet (starting in Section 7-5).

  • You, your doctor, or another designated representative must contact UnitedHealthcare within 60 days of the original coverage decision. If someone else is representing you, you need to submit an Appointment of Representative form to UnitedHealthcare.
  • For a standard appeal, you must provide a written request. For a fast appeal, you or your doctor must ask and can make the request either in writing or by phone.
  • You can now ask UnitedHealthcare for documents and information related to your appeal. You and your doctor can also provide additional information to support your appeal. This can be things like medical records, proof of out-of-pocket costs or claim documentation.
  • UnitedHealthcare’s timing of the appeal answer after the receipt of your request depends on the type of request:
  • Standard Part C Pre-Service or Benefit are within 30 calendar days.
  • Standard Part B Drug Request are within seven calendar days.
  • Expedited Part C Pre-Service, Benefit or Part B Drug Request are within 72 hours.
  • Payment Requests are within 60 calendar days.
    • Some medical appeal decisions can take up to 14 more calendar days. You’ll be notified if this applies to you. You have the opportunity to contest this decision (see Section 7-14 of your TRS-Care Medicare Advantage Benefits Booklet). Decisions regarding coverage for prescription drugs will not take additional time.
  • If UnitedHealthcare denies all or part of your request, your case will automatically go to a Level 2 appeal with an IRO hired by Medicare. You don’t need to request to move to this level.

  • The IRO will begin their review and send you information about your appeal – your “case file.” If your Level 1 appeal was a fast appeal, it will also be a fast appeal during Level 2.
  • You can now give the IRO additional information to support your appeal if you choose to do so.
  • The IRO will let you know their decision within the same time frames mentioned in the Level 1 section.
    • Some decisions for medical appeals can take up to 14 more calendar days.
  • If the IRO denies your appeal, you may qualify for a Level 3 appeal. You’ll get instructions about the Level 3 process when you get your Level 2 decision. Remember, you can choose to accept the decision made in the Level 2 appeal.

To qualify for a Level 3 appeal, your medical procedure or prescription must meet a minimum dollar value that is determined on a case-by-case basis. Appeal Levels 3 – 5 involve review from a judge, attorney, or council affiliated with the federal government. Each review works in a similar fashion, and UnitedHealthcare can appeal any decision made in your favor during these levels. Here’s what to expect:

  • If the judge says yes to your appeal in Level 3, UnitedHealthcare can choose to dispute the decision. If they do, you’ll move to Level 4 and UnitedHealthcare will let you know in writing.
  • If the judge says no to your appeal in Level 3, you can request to move to Level 4 where the Medicare Appeals Council will review your case. The council is part of the federal government.
  • If the council says yes to your appeal in Level 4, UnitedHealthcare can choose to dispute the decision. If they do, you’ll move to Level 5 and UnitedHealthcare will let you know you in writing.  
  • If the council says no to your appeal in Level 4, you’ll receive the notice in writing. The notice will include rules as to whether you qualify for a Level 5 appeal. If you do, you can choose to move to this final stage.
  • In a Level 5 appeal, a judge at the federal district court will review your case.
  • The decision made by the judge is final.

Detailed information about these appeal levels are provided in more detail starting in Section 7-33 of your TRS-Care Medicare Advantage Benefits Booklet.

  • Fast Coverage Decisions and Appeals

    You may qualify for a fast coverage decision or fast appeal. This means decisions happen within 72 hours for medical services or procedures and Medicare Part B prescription drugs.
    Requirements for fast coverage decisions and appeals:

    • Must be for medical care or prescriptions you haven’t received.
    • Can only be used if the standard deadlines could cause serious harm to your health or hurt your ability to function.

    However, if your provider says it’s necessary, you’ll automatically get a fast coverage decision.

  • Hospital Discharge Appeals

    ​If you're getting inpatient care at a hospital facility and feel you’ll be discharged too soon, you can ask for a longer stay with an appeal.

    This process is like the other appeals processes but, the review is conducted by a Quality Improvement Organization for Texas that will check if your planned discharge date is medically necessary. The organization is still affiliated with the federal government and paid by Medicare.

    You should always ask for a “fast review” and act quickly during this process.

    The steps for this type of appeal are detailed beginning in Section 7-19 of your TRS-Care Medicare Advantage Benefits Booklet.

  • Home Healthcare, Skilled Nursing Care, and Rehab

    ​There is another appeal process specific to these three areas of care. It’s similar to the hospital discharge process and is conducted by a Quality Improvement Organization for Texas. The organization is affiliated with the federal government and paid by Medicare.

    Again, you should also always ask for a “fast review” and act quickly during this process.

    The steps for this type of appeal are detailed beginning in Section 7-26 of your TRS-Care Medicare Advantage Benefits Booklet.
     

​​If you still have questions about or need help during the appeals process, call UnitedHealthcare Customer Service toll free at 1-866-347-9507 Mon.–Fri., 7 a.m.–6 p.m.

The TRS Health can provide guidance but cannot get involved in the process. You can contact TRS Health customer service at 1-888-237-6762, Mon.–Fri., 7 a.m.–6 p.m.

Quick Glossary

Benefits Determination: A decision BCBSTX makes about whether or not your plan will pay for some or all of your requested medical service or procedure.

Adverse Benefits Determination: This is a partially or fully denied medical claim. If you refer to your TRS-ActiveCare or TRS-Care Standard Benefits Booklet, this is the term that will be used.

Final Internal Adverse Benefits Determination: When your claim is still fully or partially denied after an internal appeal. You still have the right to an external review after this decision. If you refer to your TRS-ActiveCare or TRS-Care Standard Benefits Booklet, this is the term that will be used.

Independent Review Organization (IRO): An organization not affiliated with your medical administrator who conducts a separate, non-biased review of your appeal. IRO’s used for TRS-Care Medicare Advantage are hired by Medicare but not part of the Federal government.

Urgent Care Claim Review: A faster review of your medical service or procedure claim when the decision will immediately impact your health.

External Review: A review by an IRO after BCBSTX has denied your claim during their internal review process. You need to request this review.

Standard Coverage Decision: A decision by UnitedHealthcare about whether a service, procedure, or prescription is covered, and how much they will pay.

Fast Coverage Decision: A faster coverage decision process for when your health is at immediate risk. Sometimes this is called an expedited coverage decision. You or your provider will need to request this type of decision. You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received

Appeal: A request that UnitedHealthcare review a decision that partially or fully denied a benefit or payment.

Fast Appeal: A faster appeal process for when your health is at immediate risk. You need to request this type of appeal if it’s for a previously denied standard coverage decision.

Medicare Appeals Council (UHC): A part of the Federal government that will review your appeal and give you an answer.  

Fast Review: A faster review process for when a Quality Improvement Organization (QIO) makes decisions about hospital stays, home health care, skilled nursing facility care, and rehabilitation facilities.

Quality Improvement Organization: A group of doctors and other health care professionals who are paid by the Federal government to check on and improve the quality of care for people with Medicare.

Customer Service Info

Customer Service ProviderContact NumberHours (CT)
Blue Cross and Blue Shield of Texas1-866-355-599924 hours a day, 7 days a week
UnitedHealthcare1-866-347-9507Mon.–Fri., 7 a.m.–6 p.m.
TRS Health and Insurance Benefits Department1-888-237-6762Mon.–Fri., 7 a.m.–6 p.m.