1. (a) A person enrolled in the TRS-ActiveCare program who is denied payment of a claim or other benefit ("Claimant") may submit a written request to the administering firm for reconsideration of the claim. The claimant shall submit a request for reconsideration according to procedures established by the administering firm. All relevant medical information should be submitted to the administering firm prior to a final decision.
2. (b) A claimant may appeal the final denial of a claim or other benefit by the administering firm to the Teacher Retirement System of Texas (TRS), acting in its capacity as trustee of the TRS-ActiveCare program.
3. (c) An appeal of a final denial of a claim or other benefit by the administering firm must be submitted in writing and received by TRS no later than 60 days after the date of the letter from the administering firm finally denying the claim. The appeal shall be directed to the attention of the TRS-ActiveCare Grievance Administrator.
4. (d) An appeal of denial of a claim shall state the nature of the claim and shall include copies of all relevant documents that were considered by the administering firm, including copies of the correspondence to and from the administering firm.
5. (e) The TRS Appeal Committee ("Committee") is responsible for review and determination of appeals. The Committee shall be appointed by the TRS Deputy Director and shall serve at the discretion of the Deputy Director.
6. (f) The Committee shall review an appeal for timeliness and sufficiency and may deny an appeal that is not timely filed. Denial of an appeal for failure to file in a timely manner is a final decision by TRS.
7. (g) If the Committee determines that the claim should be paid, it shall so inform the administering firm and the claimant.
8. (h) If the Committee determines that the information submitted with the appeal supports the denial by the administering firm, the Committee shall provide a written explanation of the reasons to the claimant and to the administering firm. The explanation shall include information on how the claimant may request an appeal conference.
9. (i) To obtain an appeal conference, a claimant must submit a request in writing to the TRS-ActiveCare Grievance Administrator no later than 45 days after the date of the written explanation of the Committee.
10. (j) Upon receipt of a timely request for an appeal conference, the TRS-ActiveCare Grievance Administrator shall schedule an appeal conference with the Committee. The Grievance Administrator shall notify the claimant and the administering firm of the time, date, and manner of the conference, as well as the procedures applicable to the conference.
11. (k) At any time prior to the appeal conference, the Committee may decide to grant the appeal and will notify the claimant of this determination without the necessity of an appeal conference. The Committee can not deny a claim after an appeal conference has been requested without holding the conference.
12. (l) At the conference, the Committee shall consider the medical information previously submitted to the administering firm in support of the payment of the claim or benefit, as well as the administering firm's determination regarding medical issues. The Committee may request additional review by the administering firm on medical issues before the Committee issues a decision.
13. (m) The Committee shall decide the appeal and shall notify the claimant and the administering firm of the decision in writing. The decision will include an explanation of the basis for the decision.
14. (n) The decision of the Committee may be appealed by the claimant to the TRS Executive Director. An appeal to the Executive Director shall be submitted to TRS in writing no later than 30 days after the date of the written decision by the Committee. The appeal shall specifically describe why the claimant alleges that the Committee's decision is erroneous. The Executive Director shall make a decision based on the written appeal and based on the written decision of the Committee, as well as any written documents reviewed by the Committee. Pursuant to the delegation of authority through this section, the decision of the Executive Director is the final decision of TRS.

Source Note:The provisions of this §41.50 adopted to be effective December 26, 2002, 27 TexReg 12004; amended to be effective October 27, 2003, 28 TexReg 9289.