Claims and Coverage FAQs

You can review details about all your UT CARE health plan coverage and benefits when you:

1. Go to the Coverage page.
2. Log in to Blue Access for Members^SM, your online account. Select Coverage and Benefits for an overview of your coverage, important documents, a cost estimator tool and more. 
3. Review the Plan Overview Chart .

An Explanation of Benefits is a statement that breaks down the health care services you received, the cost of the services and what portion you might have to pay out of pocket. You receive an EOB every time your UT CARE plan processes a health care claim. Take a look at this sample EOB for details about all the information included. It’s important to check an EOB as soon as you receive it to make sure everything is accurate. If you get paper EOBs, they will be mailed to you after a claim has been finalized. If you signed up for paperless statements, you'll get an email when your EOB is ready to view in your online account. 

Some health care services must be approved by Blue Cross and Blue Shield of Texas before they are covered under your plan. Things like diagnostic images and complex care need preauthorization before you are treated. Preauthorization for MRIs and CT scans is standard. Your care provider will know to ask first, but don’t be afraid to make sure. Each plan is different, so it's always good to ask.

Drugs that may be unsafe when used with other medications need preauthorization. Some drugs that are FDA-approved for one health condition but are being prescribed for a different health issue may need review. Drugs that are often misused may also be on the preauthorization list. 

Your doctor will submit a preauthorization request before ordering a test or medication. If the request for preauthorization isn't approved, your insurer will let you and your doctor know. If that happens, you and your doctor may choose another treatment option or offer more information so the request can be reviewed again.

If your providers aren't in network, you'll be responsible for getting the preauthorization. If you don't, your health plan may not cover the cost.

Learn more about your plan’s preauthorization requirements.

To see your claims online, log in to Blue Access for Members℠ , your online account, or use the BCBSTX Mobile App. After you log in, go to Claims to:

• Access up to 18 months of claims.
• Filter information by member, claim type, claim status and provider to easily find the information you need. 
• ​Download or print claim information.

To check the status of a claim, log in to your online account and go to Claims. You can also sign up to get alerts about claims via your online account. Keep in mind that your online account will not have updates on your claim until it is submitted and processed.

Most claims are denied for the same reasons.

1. Your claim has errors. 
2. Your care needed approval ahead of time.
3. You received care that isn’t covered by your health plan.
4. Your claim went to the wrong insurance agency.

If your claim is denied, check your Explanation of Benefits to find out why. Your EOB will list a code that shows the reason it was denied. The EOB also includes a key to the code that explains what the code means.

First, review your Explanation of Benefits to find out why the claim was denied. If a simple mistake was made on the claim, like the wrong birth date or a different home address, you can give us a call at 1-877-842-7562 TTY 711 to easily correct it. 

You can also check with your provider. They are notified when a claim is denied and may know what needs to be fixed so it can be resubmitted.

If your claim isn’t approved based on medical necessity, you can ask a second medical reviewer to look at the request. This external review is done by an independent review organization outside of Blue Cross and Blue Shield of Texas. Your Explanation of Benefits notes what types of denials can be sent for external review. There is no cost to you for an external review. A standard appeal takes about 30 days. Other appeals may take up to 60 days.