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Benefits & Welfare
Appeals/Grievances

HMO/DMO Appeals

The Texas Insurance Code does not give the Employees Retirement System (ERS) authority to review HMO and/or Dental HMO claims and benefit denials.  If you are enrolled in an HMO or Dental HMO, your right to appeal claims and benefits denials is restricted to the HMO.  You may also register a complaint with the Texas Department of Insurance at 800-252-3437.

Steps in the Appeals Process

1. Ask the Benefits Administrator (i.e., BCBS, Fort Dearborn Life, GEHA) to reconsider the original claim or application.

   • Call or write the Benefits Administrator (see addresses below).

   • ERS will consider your appeal AFTER you have received a letter of explanation from the appropriate Benefits Administrator.

    

2. Ask ERS staff to review administrator's denial (see ERS address below).

   • This must be done within 90 calendar days of receipt of the Administrators letter of explanation.

   • You lose your right to appeal if your appeal is not postmarked or received by ERS within this 90-day period.

   • You may include a written explanation of your position and any documentation that you believe is relevant.

   • ERS will send you a letter letting you know that the appeal has been received.

   • The ERS Staff's decision will be sent to you by certified mail.

    

3. Ask ERS Board of Trustees to review ERS staff decision and hearings examiner's recommendation.

   • You have the right to appeal the ERS staff's decision to the ERS Board of Trustees.

   • Your appeal must be in writing.

   • Your appeal must be postmarked or received by ERS no later than 30 calendar days after the date of your certified letter from ERS.

   • Upon receipt of your appeal, a hearing date will be set.

   • ERS and the Benefits Administrator will have legal representation at this hearing.

   • You may represent yourself, or have legal representation at this hearing, however, you are responsible for any fee to which your representative may be entitled.

   • The hearings examiner will make a recommendation and present it to the ERS Board of Trustees.  You and/or your representative may attend the meeting and address the Board.

   • If you are not satisfied with the Boards decision, you may file a written Motion for Rehearing with ERS within 23 calendar days of the date of the order.

    

4. Ask Travis County District Court to review ERS Board decision

   • If your motion for Rehearing is denied, you have the right to file suite in Travis County District Court asking the Court to review the decision of the ERS Board of Trustees.

   • The Court will review the evidence presented in the earlier administrative hearing and determine whether the ERS Board's decision was reasonable.

HealthSelect

BlueCross BlueShield of Texas

800/252-8039

P.O. Box 833988

Richardson, TX  75083-3988

Prescription Drug Program

Medco Prescription Services

800/753-2851

P.O. Box 650322

Dallas, TX  75265-0322

Life, Accident, Disability, Evidence of Insurability

Fort Dearborn Life Insurance Company

Group Life and Health Division

800/451-0271

P.O. Box 655403

Dallas, TX  75265-5403

Dental Choice Plan

State of Texas Dental Choice Plan
P.O. Box 100
Independence, MO 64051-0100

Dental HMO

Employees Retirement System of Texas

Grievance Administrator

P.O. Box 13207

Austin, TX  78711-3207

Click here for more information regarding Appeals/Grievances with HealthSelect for a denied claim or EOI.