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How to Navigate the Appeals Process with Blue Cross and Blue Shield of Texas

Filing an appeal with Blue Cross and Blue Shield of Texas (BCBSTX) is a structured process designed to address concerns regarding denied services or claims. Understanding the available avenues and adhering to the specified procedures can enhance the likelihood of a favorable outcome.


When to File an Appeal

You may consider filing an appeal if:

  • A requested service was denied.

  • Not all requested services were approved.

  • A previously approved service is being discontinued.

  • There are delays in receiving the requested service.

Your appeal can be filed by you, your healthcare provider, a friend, relative, lawyer, or any chosen representative. BCBSTX will reassess your case upon receiving the appeal.


How to File an Appeal

To initiate an appeal, you can:

  1. Submit a Written Appeal: Complete the Health Plan Appeal Request Form, which can be downloaded here. Mail or fax it to the address or fax number listed at the top of the form.

  2. Call the Customer Advocate Department: Reach out toll-free at 1-888-657-6061 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.

  3. Email: Send your appeal to GPDTXMedicaidAG@bcbsnm.com.

  4. Mail: Address your appeal to:

Blue Cross and Blue Shield of Texas

Attn: Complaints and Appeals Department

P.O. Box 660717

Dallas, TX 75266-0717

  1. Seek Assistance from a Member Advocate: For help with filing an appeal, contact 1-877-375-9097 (TTY: 711)


Important Timelines

  • Standard Appeal: Must be filed within 60 days from the date of the denial notice. BCBSTX will provide a decision within 30 days.

  • Continuation of Services: To continue receiving services during the appeal process, request this within 10 days from the date the denial notice was mailed or from the date services are set to change.


Pharmacy Appeals

For pharmacy-related appeals:

  • Call: 1-888-657-6061 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.

  • Mail: Send a written appeal to:

Blue Cross and Blue Shield of Texas

Attn: Prime Therapeutics Appeals Department

2900 Ames Crossing Road

Eagan, MN 55121

  • Fax: 1-855-212-8110.

  • Online Submission: Your doctor can submit the appeal through MyPrime.com or CoverMyMeds.com.


Emergency (Expedited) Appeals

If waiting for a standard appeal decision could seriously harm your health, you or your doctor can request an expedited appeal. BCBSTX is required to decide on such appeals within 72 hours of the request.


State Fair Hearings and External Medical Reviews

If your appeal is denied, you have the right to:

  • Request a State Fair Hearing: This involves the Texas Health and Human Services Commission (HHSC) reviewing BCBSTX's decision regarding your medical care. You or your representative must request this hearing within 120 days of the internal appeal decision.

  • Seek an External Medical Review: An Independent Review Organization (IRO) will conduct this review during the appeal process, especially for determinations based on medical necessity. Contact BCBSTX at 1-888-657-6061 (TTY: 711) or the 24-Hour Nurse Advice Line at 1-844-971-8906 for more information.


Contact Information

  • BCBSTX Customer Advocate Department: 1-888-657-6061 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.

  • STAR Member Advocate: 1-877-375-9097 (TTY: 711).

  • HHSC Office of Ombudsman:

    • Phone: 1-877-787-8999 (TTY: 1-800-735-2989 or 7-1-1).

    • Mail: Texas Health and Human Services Commission Office of the Ombudsman MC H-700P, P.O. Box 13247, Austin, TX


Need Expert Help? Contact Appealing Solutions Medical Advocacy Partners (ASMAP)

Navigating the appeals process can be overwhelming. That’s where Appealing Solutions Medical Advocacy Partners (ASMAP) comes in. We provide professional medical appeals advocacy to ensure that you have expert guidance every step of the way.


Why Choose ASMAP?

  • Experienced Advocates: Our team has extensive knowledge of the appeals process and insurance policies.

  • Personalized Assistance: We tailor our approach to your specific situation.

  • Time-Saving Service: We handle the paperwork and communication, so you don’t have to.

  • Higher Success Rates: Our expertise increases your chances of a favorable outcome.


Contact ASMAP Today!

📍 Appealing Solutions Medical Advocacy Partners

📞 Phone: 303-503-7747

🌐 Website: www.asmapartners.com


Don’t navigate the appeals process alone. Let ASMAP fight for you! Contact us today for a free consultation.

 
 
 

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