Your Appeal Rights Under the Affordable Care Act

1. "Authorized Representative" means a person authorized to act on behalf of a Participant and does not include a Provider or other entity acting as an assignee of a Participant's claim. Please contact BCBSTX for information on how to properly designate an Authorized Representative. An Authorized Representative must be properly designated in order to protect against improper disclosure of information about a Participant including protected health or other confidential information.
2. "Claimant" means an individual (Participant, including an Authorized Representative of a Participant) who makes or appeals a claim solely on behalf of the Participant.
3. "Pre-service claim" means a claim made before services are provided for treatment.
4. "Urgent Care claim" can be summarized as a Pre-service claim for medical care or treatment with respect to which the application of the timeframes for making non-urgent care determinations could seriously jeopardize the life or health of the Claimant or the ability of the Claimant to regain maximum function, or in the opinion of the Claimant's physician, would subject the Claimant to severe pain that could not be adequately managed without the care or treatment.
5. "Post-service claims" or "Post-service appeals" means a claim or appeal that is not a Pre-service claim or appeal, generally, a claim or appeal made after a Claimant receives medical services.

2.1 BCBSTX Pre-service Urgent Care Claim Appeals Process

2.1(a) BCBSTX Expedited Internal Appeals Process:

2.1(a)(1) If an Urgent Care claim is denied by BCBSTX, the Claimant can appeal BCBSTX's decision.

• Claimants and/or a Claimant's Provider may request an appeal after receiving a denial of an Urgent Care claim from BCBSTX. The request may be made by phone or in writing.
• BCBSTX will conduct a preliminary review of the appeal. As appropriate, BCBSTX will also review any claims for non-urgent care to be provided at the same time as a Claimant's proposed urgent care treatment. If additional information is needed for BCBSTX to render a decision, BCBSTX will notify a Claimant and the Claimant's Provider within 24 hours.
• Within 48 hours of receiving all necessary information, BCBSTX will notify Claimant and Claimant's Provider of its decision and the reasons for the decision.
• If the denial is overturned, BCBSTX will notify the Claimant and Claimant's Provider immediately so that services are authorized.
• If the denial is upheld, BCBSTX will notify the Claimant and Claimant's Provider of the reasons and will provide Claimant and the Claimant's Provider with a description of the external review procedures. ERS does not review Pre-service denials.

2.1(b) Expedited External Review Process for Pre-Service Urgent Care Claim Denial:

A Claimant with an Urgent Care claim denial may file a request for an expedited external review at the same time the Claimant files an expedited internal appeal. BCBSTX will review the request to determine if the Claimant's appeal should go straight to external review instead of through the expedited internal review process.

If the claim meets the criteria for expedited external review, BCBSTX will assign the Claimant's case to an Independent Review Organization (IRO) immediately. The IRO will review the appeal and notify the Claimant and the Claimant's Provider of its decision and the reasons for its decision as soon as possible but not more than 72 hours after receiving your appeal. If the request does not meet the expedited external review criteria as determined by BCBSTX, the appeal will be handled as an expedited internal appeal.

A denial of any claims for services does not mean that the Claimant cannot have the treatment. A denial of the claim simply means that the services are not covered under the Plan, and no payments will be made to any Providers or to the Claimant by the Plan if you receive the denied services unless Claimant wins their appeal.

A Claimant may choose, at any time while an Urgent Care claim is pending, to have the medical care or treatment performed immediately. The Claimant may thereafter seek reimbursement of the claim payment pursuant to section 3 below. However, a Claimant is not entitled to a second IRO, and the denial of a claim by an IRO is binding on a Claimant without further administrative remedies.

2.2 BCBSTX Non-Urgent Care Pre-Service Appeal Process

• If a non-urgent Pre-service claim is denied by BCBSTX, a Claimant may appeal BCBSTX's decision.
• Claimants may request an appeal after receiving the denial of the non-urgent Pre-service claim from BCBSTX. The request may be made by phone or in writing within 180 days of the denial.
• For a non-urgent Pre-service appeal, BCBSTX will send Claimant an acknowledgement letter and allow Claimant the opportunity to submit written comments and other relevant information. BCBSTX will make its decision on the appeal within 15 days of receiving the appeal provided all information relevant to the claim has been received by BCBSTX.
• If the denial is upheld, BCBSTX will notify the Claimant of the reasons for its decision and allow Claimant the opportunity to appeal a second time through BCBSTX. The second appeal must be received by BCBSTX within 90 days of BCBSTX's decision on the first appeal.
• If the denial is overturned, BCBSTX will notify the Claimant of its decision and approve benefits for the services that were requested.
• If a Claimant submits a request for a second appeal through BCBSTX, then BCBSTX will respond to the second appeal within 15 days of receiving the appeal provided all information relevant to the claim has been received by BCBSTX.
• If the denial is upheld, BCBSTX will notify the Claimant of the reasons for its decision and that the Claimant's internal appeals rights are exhausted. If a claim and appeal involved issues of medical judgment, the Claimant may request an external review. See the External Review section below.
• If the denial is overturned on the second appeal, BCBSTX will send a letter to the Claimant of its decision and approve benefits for the services that were requested.
• The time frames for BCBSTX to respond to Pre-service claim appeals may be extended if additional information is needed to complete the review and make a decision or if other special circumstances warrant an extension.

3.1 Post-Service Appeal Process — First Appeal to BCBSTX

• If a claim is denied after a Claimant receives medical care or treatment, the Claimant can appeal through BCBSTX. The Claimant can request the appeal by phone or in writing within 180 days of the claim being denied.
• For Post-service appeals, BCBSTX will send the Claimant an acknowledgement letter and allow the Claimant the opportunity to submit written comments and other relevant information. BCBSTX will make its decision on the appeal within 30 days of the date the initial appeal was received provided all information relevant to the claim has been received by BCBSTX.
• If the denial is upheld, BCBSTX will send a letter to the Claimant notifying the Claimant of the reasons for its decision and that Claimant has 90 days to file a written grievance appeal to ERS.
• If the denial is overturned, BCBSTX will send a letter to the Claimant of its decision and pay applicable claims as appropriate.

3.2 Post-Service Appeals to ERS — ERS Grievance Process

• A Claimant may request a grievance appeal in writing to ERS after BCBSTX' final denial of the Claimant's Post-service appeal. The grievance appeal request must be made in writing by Claimant, and received by ERS within 90 days following the appeal denial by BCBSTX. ERS' review of the Post-service claim will be completed pursuant to the deadlines (and subject to extensions) as provided by the applicable state and federal laws and regulations.
• If the denial is upheld, ERS will send a letter to the Claimant stating the reasons for its decision, and the letter will inform the Claimant that the Claimant's internal appeals rights are exhausted. If a Claimant's appeal is denied and it involves issues of medical judgment or a rescission of coverage, the Claimant may then request an external review pursuant to section 4 below.
• If the denial is overturned, BCBSTX will send a letter to the Claimant of the decision and pay applicable claims, as appropriate.
• The time frames for BCBSTX or ERS to respond to Post-service claims or appeals may be extended if additional information is needed to complete the review and make a decision or if other special circumstances warrant an extension.

4.1 Standard External Appeal-For Medical Judgment and Rescission of Coverage Issues After Internal Appeals are Completed:

• After a Claimant has completed both internal appeals for Post-service claims, a Claimant may request an external review by an IRO.
• Claimant's request must be made within four (4) months of the final internal appeals decision. To request an external review by an IRO, contact BCBSTX by phone or in writing.
• BCBSTX will send the Claimant an acknowledgement letter within five (5) days of receiving a request for an IRO review. BCBSTX will forward appeals information to the IRO for its review. Claimant may send additional information to the IRO for consideration.
• Within 45 days of receiving the Claimant's request, the IRO will notify Claimant and BCBSTX of its decision and the reasons for its decision.
• If the denial is upheld by the IRO, the Claimant will have no further appeal rights.
• If the denial is overturned, BCBSTX will notify the Claimant within 48 hours of receiving the IRO's decision, and approve requested services or pay applicable claims, as appropriate, pursuant to the Plan's requirements.