TEXAS DEPARTMENT OF INSURANCE 333 Guadalupe, Austin, Texas 78701 PO Box 149104, Austin, Texas 78714-9104 (512) 676-6000 (800) 578-4677 I TDl.texas.gov @TexasTDl May 31,2018 Nancy C. Pruitt Sent via email Divisional Sr. Vice President Enterprise Plan Counsel Blue Cross Blue Shield of Texas PO. Box 655730 Dallas, TX 752656730 Dear Ms. Pruitt: Thank you for your May 16, 2018, response to me and for Tuesday?s meeting between Dr. McCoy and Commissioner Sullivan about the Blue Cross Blue Shield of Texas? Emergency Bene?t Management Process. We appreciate the information you have provided on this issue and your agreement to delay implementation of this policy for 60 days. As we continue to evaluate process, we request the following additional information. Please provide the company?s response to these questions by June 15, 2018. 1. Please explain the reasons for the process, including any data that supports the need for the process. 2. Has communicated concerns about fraud, waste or abuse associated with emergency room (ER) claims to appropriate regulatory agencies, such as the Of?ce of the Attorney General, TDI's Fraud Unit, the Department of State Health Services, or the Texas Medical Board? 3. states all denials will be issued by a medical director. 21. Under what circumstances will a denial be made under a claims review process, and under what circumstances will an adverse determination letter be issued under a utilization review process? b. What appeal rights are provided to the member when the entire claim is denied as a non? covered service? How will the denial be communicated to the member and provider? c. Is an adverse determination letter issued to the member and provider if services were medically necessary, but the medical director determines parts of the claim should be denied because the level of care billed is not supported by the medical records? If not, how will the denial be communicated to the member and provider? Nancy C. Pruitt May 31, 2018 Page 2 d. Is a peer-to-peer conversation offered when the medical director is contemplating a partial or total claim denial? 4. Will members have the opportunity to submit justi?cation, including a description of their for seeking emergency services under the prudent layperson standard before a claim denial? If yes, what is the process for to obtain this information from members? 5. indicates fully-insured retail and group HMO and FPO members with a current email address on ?le received or will receive an email about the new policy. Why are PPO members receiving this email? How will this policy be communicated to members without email addresses? 6. How does plan to ensure members and providers understand the process? Will there be additional education and outreach to members and the medical community? If yes, please describe. TDI may have further questions or require additional documentation to ensure the process complies with requirements and protects Texans. Please let me know if you have any questions or need additional information. I serve as the lead staff on this matter and can be reached by telephone at 512-676-6213 or by email at Sincerely, Melissa Hield Associate Commissioner