1. (a) For appeals that relate to claims or other benefits and that are received on or after September 1, 2011, the following procedures apply:

   1. (1) A person enrolled in TRS-ActiveCare, other than a person enrolled in a health maintenance organization (HMO) participating in TRS-ActiveCare, who is denied payment of a claim or other benefit ("Claimant") may appeal the denial through a written request filed with the administering firm in accordance with procedures established by the administering firm.
   2. (2) The final decision by the administering firm or by any external review organization, whichever occurs later, shall be the final decision on the appeal.

2. (b) For appeals that relate to claims or other benefits and that are received before September 1, 2011, the following procedures apply:

   1. (1) A Claimant may appeal the denial through a written request filed with the administering firm in accordance with procedures established by the administering firm. All such procedures must be exhausted before the administering firm will issue a final decision.
   2. (2) A Claimant may appeal the final denial of the claim or other benefit by the administering firm to the Teacher Retirement System of Texas (TRS), acting in its capacity as trustee of TRS-ActiveCare.
   3. (3) An appeal made pursuant to paragraph (2) of this subsection must be submitted by the Claimant in writing and received by TRS before September 1, 2011 and 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. (4) An appeal made pursuant to paragraph (2) of this subsection 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. (5) The TRS Appeal Committee ("Committee") is responsible for review and determination of appeals made pursuant to paragraph (2) of this subsection. The Committee shall be appointed by the TRS Deputy Director or, if the position of the Deputy Director is vacant, the TRS Chief Financial Officer and shall serve at the discretion of the Deputy Director or, if the position of the Deputy Director is vacant, the Chief Financial Officer.

   6. (6) The Committee shall apply the TRS-ActiveCare plan design and rules in effect on the date the first of the following events occurs:

      1. (A) the date the claim was incurred; or
      2. (B) the date the benefit was denied by the administering firm.
   7. (7) If the Committee determines that the claim should be paid or a benefit allowed, it shall so inform the administering firm and the Claimant.
   8. (8) If the Committee determines that the information submitted with the appeal supports the denial by the administering firm, the Committee shall provide a written decision, which shall include an explanation of the reasons for the decision, to the Claimant and to the administering firm. The written decision shall include information on how the Claimant may request an appeal conference or an appeal to the executive director.
   9. (9) The initial written decision of the Committee may be appealed by the Claimant to the Committee for an appeal conference. A request for an appeal conference must be submitted by the Claimant in writing and must be received by TRS no later than 45 days after the date of the initial written decision by the Committee. The request for an appeal conference shall be directed to the attention of the TRS-ActiveCare Grievance Administrator.
   10. (10) 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. (11) 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 cannot deny a claim after an appeal conference has been requested without holding the conference, but the initial denial by the Committee shall stand until the conference is held.
   12. (12) 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. (13) 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. (14) The initial written decision of the Committee or the written decision by the Committee made pursuant to an appeal conference may be appealed by the Claimant to the executive director. A request for an appeal to the executive director must be submitted by the Claimant in writing and must be received by TRS no later than 45 days after the date of the initial written decision by the Committee or no later than 30 days after the date of the written decision by the Committee made pursuant to an appeal conference. The request for an appeal to the executive director shall be directed to the attention of the TRS-ActiveCare Grievance Administrator. 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. Subject to paragraph (15) of this subsection and pursuant to the delegation of authority through this section, the decision of the executive director is the final decision of TRS.
   15. (15) The Committee shall review an appeal made pursuant to paragraph (2), (9), or (14) of this subsection for timeliness and may deny an appeal that is not timely received by TRS. An appeal made pursuant to paragraph (2), (9), or (14) of this subsection that is denied because TRS did not timely receive the appeal is a final decision by TRS.
3. (c) For appeals that relate to claims or other benefits, persons enrolled in an HMO under contract with TRS-ActiveCare shall follow the appeal procedures set out by the HMO.

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; amended to be effective April 28, 2004, 29 TexReg 3969; amended to be effective August 25, 2004, 29 TexReg 8134; amended to be effective March 8, 2007, 32 TexReg 1092; amended to be effective March 25, 2008, 33 TexReg 2556; amended to be effective April 1, 2011, 36 TexReg 2001; amended to be effective September 1, 2011, 36 TexReg 5380; amended to be effective December 22, 2014, 39 TexReg 10029.