Claim Review Process

Claim review requests must be submitted in writing on the Claim Review  form.

There are two (2) levels of claim reviews available to you.

For the following circumstances, the 1st claim review must be requested within the corresponding timeframes outlined below:

Dispute TypeTimeframe For Request
Audited Payment Within 30 days following the receipt of written notice of request for refund due to an audited payment
Overpayment Within 45 days following the receipt of written notice of request for refund due to overpayment
Claim Dispute Within 180 days following the check date/date of the HMO Blue® Texas Explanation of Payment (EOP), or the date of the BCBSTX Provider Claims Summary (PCS), for the claim in dispute


  • BCBSTX / HMO Blue® Texas will complete the 1st claim review within 45 days following the receipt of your request for a 1st claim review.
  • You will receive written notification of the claim review determination.

If the claim review determination is not satisfactory to you, you may request a 2nd claim review. The 2nd claim review must be requested within 15 days following your receipt of the 1st claim review determination.

  • BCBSTX / HMO Blue Texas will complete the 2nd claim review within 30 days following the receipt of your request for a 2nd claim review.
  • You will receive written notification of the claim review determination.

The claim review process for a specific claim will be considered complete following your receipt of the 2nd claim review determination.

For those claims which are being reviewed for timely filing, BCBSTX will accept the following documentation as acceptable proof of timely filing:

  • TDI Mail Log
  • Certified Mail Receipt (only if accompanied by TDI mail log)
  • rEDI-link Blue Claim Acceptance Response Report
  • Above documentation indicating that the claim was filed with the wrong division of Blue Cross and Blue Shield of Texas
  • Documentation from BCBSTX indicating claim was incomplete
  • Documentation from BCBSTX requesting additional information
  • Primary carrier's EOB indicating claim was filed with primary carrier within the timely filing deadline.

Mail the completed Claim Review  form, along with any attachments, to the appropriate address indicated on the form.

If you have any questions concerning the process for claim reviews, please contact your Provider Relations or Provider Contracting office.