Timely filing of appeal or grievance with PPO per Texas state health insurance law?

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Jul 18, 2010

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Insurance Question from Fort Worth, TX

Asked on 07/18/2010

Timely filing of appeal or grievance with PPO per Texas state health insurance law? I was denied a procedure by my PPO. My physician claims they have had approval from my PPO to perform this procedure on other patients and has no insight on what makes my request different to my PPO.The procedure was FDA approved for the treatment of uterine fibroids in 2004. My PPO categorizes this procedure -MRI-guided focused Ultrasound- as "experimental." Specific to Texas state insurance law how long do I have to file appeals/grievences? I understand under ERISA I may have longer than my PPO says and as of last week I've missed the second appeal deadline stated by my PPO.

Answer given on July 19, 2010

Here is a helpful link for you.

 

https://wwwapps.tdi.state.tx.us/inter/perlroot/consumer/complform/complform.html

 

You can fill out a griveance online.  As far as how long do you have to file a greivance, I have no idea. If you’ve already missed the deadline offered by the PPO contract, you may well be out of luck.

Here’s some info on TIC for pre-authorization of claims:

http://www.statutes.legis.state.tx.us/Docs/IN/htm/IN.1301.htm#1301.055

 

About two thirds of the way down the page on the above link it discusses what an insurer can/can’t do, etc.  As far as a deadline for filing a complaint, it sounds like you’ve already mussed the contractual deadline.

 

As far as ERISA goes, I’m not sure they can do much for you.  But there is a free consultation/contact link on this website, located here:

 

https://www.AdvocateLawGroup.com/

I’d start there and see what they say.

Good luck!


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