Información para asegurados

Navigate Your Medical Care: Appeals and Grievances

Learn how coverage decisions are made. You can use your rights to make an appeal or grievance. Esto es lo que debe saber:

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Medical Care Coverage Decisions

Do you want to know how coverage decisions are made? You may want to file an appeal for a denied service. Or you may need to find out how to resolve a grievance related to your health care.

Blue Cross and Blue Shield of Texas se compromete a ayudarlo en cada paso. We want you to understand your rights and options. We'll make sure that your concerns are addressed.

Ask for a Coverage Decision

You have the right to ask us to pay for an item or service you think should be covered.

Así es como funciona:

  • Coverage decisions are about your benefits and the amount we pay for your medical care or drugs.
  • When this decision involves your care, it's called an "organization determination."
  • If you want to know if we cover medical treatment before you get it, you can ask us for a coverage decision.
  • You or your doctor can ask for a coverage decision if:
    • You aren’t sure if your plan covers a medical service.
    • Care is refused for a service you think you need.

If you don't agree with our decision, you can appeal. Learn more below at "How to File a Medical Appeal”.

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Preguntas frecuentes

Apelaciones e inconformidades

To make it easy to find the information you need, just click on the arrow next to each section title below. Click the arrow again to close the section when you're done.

Ayuda de Medicare

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