Claim Review Process

Providers should review the processes available for submitting inquiries on claim processing.

Claim Reconsideration Request

Claim reconsideration requests are submitted electronically for review and/or reevaluation of situational finalized claim denials (including BlueCard^® out-of-area claims). This method of inquiry submission is preferred over faxed/mailed claim disputes, as it allows you to upload supporting documentation and monitor the status via Availity^® Essential. 

For more details, refer to the Claim Reconsideration Requests page and instructional user guide in the Provider Tools section of our website.

Claim Review Form

To request a claim review by mail, complete the Claim Review form and include the following:

• Reason for claim review request – use the Claim Review Form and Ineligible Reason Code List to determine if your claim meets eligibility requirements for review.
• 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.

Claim Review Types

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:

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

• 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 second claim review request.

• 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.

Timely Filing Reviews

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.

More information

Refer to the Provider Manuals for more information on the claim review process.. 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 additional information on NSA and the  IDR User Guide on our website for more details.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.