1. (a) Except for persons enrolled in an HMO, any person participating in the insurance program who is denied payment of insurance benefits, or otherwise receives an adverse decision, may request the carrier or administering firm to reconsider the claim. Any additional documentation in support of the claim may be submitted with the request for reconsideration. If the claim is again denied, the claim, accompanied by all related documents and copies of correspondence with the insurance carrier or administering firm, may be submitted by the person to the Executive Director of the Employees Retirement System of Texas or the Executive Director's designee for review. A request for grievance must be filed by the person in writing within 90 days from the date the insurance carrier or administering firm formally denies the claim, or provides notice of other adverse decision, and mails notice of this denial and grievance right of appeal to the person.
2. (b) Any participant with a grievance regarding eligibility or other matters involving the Program, including eligibility for participation in the premium conversion plan, may submit a written request to the Executive Director or the Executive Director's designee to make a determination on the matter in dispute.
3. (c) When the Executive Director or the Executive Director's designee reviews any matter arising under this section, all of the available information will be considered. When the Executive Director or the Executive Director's designee completes the review and makes a decision, all parties involved will be notified in writing of the decision.
4. (d) Any participant that does not accept the Executive Director's or the Executive Director's designee's decision may appeal the decision to the Board's designee provided the decision grants a right of appeal. A notice of appeal to the Board's designee must be in writing and filed with ERS 30 days from the date the Executive Director's or the Executive Director's designee's decision is mailed by certified or first class mail.
5. (e) Appeals to the Board's designee will be processed under the provisions of Chapter 67 of this title (relating to Hearings and Disputed Claims).
6. (f) As used in this section, the term "participant" includes any duly authorized representative of such person as permitted by Chapter 67 of this title.
7. (g) In computing time under this section, the day after any mailing by the carrier, Executive Director or the Executive Director's designee shall be counted as the first day of the time period. A document is considered to be filed with the Executive Director or the Executive Director's designee when it is received by the executive director or the Executive Director's designee or when it is postmarked, whichever is earlier.

Source Note:The provisions of this §81.9 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective December 31, 2003, 28 TexReg 11612; amended to be effective May 3, 2006, 31 TexReg 3588; amended to be effective December 31, 2007, 32 TexReg 10053.