Claim Review Process

Claim review requests should be submitted electronically via the Claim Inquiry Resolution (CIR) tool when available  and include the Claim Review form.

Include the following:

  • Reason for claim review request – please use the Claim Review Form and Ineligible Reason Code List to determine if your claim meets eligibility requirements for review.
  • Please be as specific as possible in detailing your request for review.
  • It is necessary to provide all required data elements and use the proper form or your review will be rejected.

Refer to the Provider Manuals for more detailed information. 

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

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

Dispute Type

Timeframe for Request

Audited Payment

Within 45 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 BCBSTX-Explanation of Payment (EOP), or the date of the BCBSTX Provider Claims Summary (PCS), for the claim in dispute

BCBSTX will complete the first claim review within 45 days following the receipt of your request for a first claim review. 

  • If your claim has been maintained after review, you will receive a written notification of the claim review determination.
  • If your claim has been overturned after reviewing your payment/PCS will serve as your notification.

If the claim review determination is not satisfactory to you, you may request a second claim review. BCBSTX will complete the second claim review within 45 days following the receipt of your request for a second claim review.

  • If your claim has been maintained after review, you will receive a written notification of the claim review determination
  • If your clam has been overturned after reviewing, your payment/PCS will serve as your notification.
  • 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)
  • Availity Electronic Batch (EBR) Response Reports
  • 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 the 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. 

Participating providers can contact your local Network Management office if you have any questions concerning the process for claim reviews.

Non-Participating Providers
If you do not have a contract with us, claims for certain services may be eligible for payment review under the No Surprises Act (NSA).  Log on to Availity® to request a claim review and initiate a negotiation (independent dispute resolution-IDR) for NSA-eligible services. See our IDR User Guide for more details.