Section 81.9 - Grievance Procedures(a) Grievance procedures regarding the denial of claims by administering firms for HealthSelect of Texas, Consumer Directed HealthSelect, State of Texas Vision and the Dental Choice Plans are set forth in the Master Benefit Plan Documents for those plans. Internal and external reviews of claims are subject to applicable federal statutes and rules and §1551.356, of the Act.(b) The review procedures for a participant in an HMO, dental health maintenance organization or a Medicare Advantage Plan who is denied payment of insurance benefits, or otherwise receives an adverse decision, are set forth in the applicable plan documents. Those decisions are not appealable to ERS.(c) Grievance procedures regarding the denial of a claim, denial of eligibility for coverage other than dependent eligibility, or other adverse decisions by a carrier or an administering firm for all GBP coverage other than those subject to subsections (a) and (b) are set forth in this subsection. A participant must request the carrier or administering firm to reconsider the denial or other adverse decision prior to seeking grievance review by ERS. Any additional documentation in support of the claim may be submitted to the carrier or administering firm with the request for reconsideration. If the claim is again denied, the claim, accompanied by all related documents and copies of correspondence with the carrier or administering firm, may be submitted by the participant to the executive director for review. A request for grievance review must be filed with ERS by the participant in writing within 90 days from the date the carrier or administering firm formally denies the claim, or provides notice of other adverse decision, and mails notice of the denial and grievance right of appeal to the participant.(d) When the executive director reviews any matter arising under this section, information available to ERS will be considered. When the executive director completes the review and makes a determination, all parties involved will be notified in writing of the decision.(e) To the extent allowed by statute, appeals of ERS' determination will be conducted under the provisions of Chapter 67 of this title (relating to Hearings on Disputed Claims) and the Act. A notice of appeal must be in writing and filed with ERS within 30 days from the date ERS' determination is served on the participant.(f) Matters initiated or referred to ERS concerning misrepresentations or fraud are not subject to grievance procedures under this rule.34 Tex. Admin. Code § 81.9
The provisions of this §81.9 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective December 31, 2003, 28 TexReg 11612; amended to be effective May 3, 2006, 31 TexReg 3588; amended to be effective December 31, 2007, 32 TexReg 10053; amended to be effective March 15, 2010, 35 TexReg 2202; amended to be effective June 12, 2012, 37 TexReg 4252; Amended by Texas Register, Volume 41, Number 36, September 2, 2016, TexReg 6755, eff. 9/5/2016; Amended by Texas Register, Volume 43, Number 12, March 23, 2018, TexReg 1876, eff. 3/27/2018