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Navigate Your Medical Care: Appeals and Grievances

Learn how coverage decisions are made. You can use your rights to make an appeal or grievance. Here’s what you need to know.

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Medical Care Coverage Decisions

Do you want to know how coverage decisions are made? You may want to file an appeal for a denied service. Or you may need to find out how to resolve a grievance related to your health care.

Blue Cross and Blue Shield of Texas is committed to helping you through each step. We want you to understand your rights and options. We’ll make sure that your concerns are addressed.

Ask for a Coverage Decision

You have the right to ask us to pay for an item or service you think should be covered.

Here’s how it works:

  • Coverage decisions are about your benefits and the amount we pay for your medical care or drugs.
  • When this decision involves your care, it's called an "organization determination."
  • If you want to know if we cover medical treatment before you get it, you can ask us for a coverage decision.
  • You or your doctor can ask for a coverage decision if:
    • You aren’t sure if your plan covers a medical service.
    • Care is refused for a service you think you need.

If you don't agree with our decision, you can appeal. Learn more below at “How to File a Medical Appeal”.

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FAQS

Appeals and Grievances

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Medicare Help

Questions About Your Rights?

We’re here to help. Call Customer Service to discuss coverage determinations, appeals and grievances. If you have problems with your Medicare plan coverage, just give us a call.