Each year, millions of claims are submitted under the various benefit plans offered through the Texas Employees Group Benefits Program (GBP). The great majority of those claims are paid with no problem. Very few of those claims, if denied, are submitted to the formal appeal process. Indeed, in 2017, Blue Cross and Blue Shield of Texas processed 6.1 million HealthSelect claims and only 460 of those were submitted for a second-level appeal—that's less than one-tenth of 1%.
Still, ERS is responsible for ensuring that you have the information you need to best understand the appeal process, should you disagree with the denial of a claim.
ERS' Participant Guide to the Appeal Process is a resource for those enrolled in HealthSelect plans (upcoming guides will address other GBP plans).
The Participant Guide to the Appeal Process describes the steps you need to take to appeal a denied claim, what happens at each phase of the process and why an appeal may be unsuccessful.
Key takeaway: Be an educated consumer. Throughout the guide, you are advised to consult the Master Benefit Plan Document (MBPD) for specific information about coverage and limitations. If you have a deep understanding of how your plan works, you are less likely to be surprised by denied claims.
Click the links below for more information:
Follow this link
to a resource from the Texas Department of Insurance that can help you become or remain a well-informed health insurance consumer.