CSHCN 2009 > Appeals and Administrative Review > Claim Appeals

7.3.5.1 Administrative Review Requirements

An administrative review is a request for a review as defined in 25 TAC §38.10 and §38.13 for claims denied by TMHP.

An administrative review must be:

•Submitted in writing to DSHS-CSHCN Services Program Administrative Review by the provider who delivered the service or received claims reimbursement for the service.

•Received by DSHS-CSHCN Services Program Administrative Review after the appeals process with TMHP has been exhausted, and must contain evidence of appeal dispositions from TMHP:

•All correspondence and documentation from the provider to TMHP, including copies of supporting documentation that was submitted during the appeal process.

•All correspondence from TMHP to the provider.

•Received by DSHS-CSHCN Services Program within 30 days of the date of disposition by TMHP as evidenced by the R&S sent to providers.

•Complete and contain all of the information necessary for consideration and determination by DSHS-CSHCN Services Program Administrative Review, including:

•A written explanation that specifies the reason for the request for review.

•Supporting documentation for the request.

•All R&S Reports that identify the claims and services in question.

•Identification of the incorrect information and the corrected information used to appeal the claim.

•A copy of the original claim, if it is available. Claim copies are helpful when the administrative review involves medical policy or procedure coding issues.

•A corrected, signed claim.

•A copy of supporting medical documentation requested by TMHP.

•Provider's internal notes and logs, when pertinent (cannot be used as proof of timely filing).

•Memos from the state or TMHP indicating any problems, policy changes, or claims processing discrepancies that may be relevant to the review.

•Other documents, such as receipts (e.g., certified mail along with a detailed listing of the claims enclosed), in-service notes, minutes from meetings, etc., if relevant. Receipts can be helpful when late filing is an issue.

Providers that have submitted their claims electronically must identify the batch submission ID with the date on the electronic claims report. This report must indicate the TMHP-assigned batch ID. In addition, this report must include the individual claim to be reviewed. This required information constitutes proof of timely filing.

Note: Only reports accepted or rejected from TMHP to the vendor will be honored. Office notes indicating claims were submitted on time or personal screen prints of claim submissions are not considered proof of timely filing.

Providers must adhere to all filing and appeal deadlines for an administrative review to be considered by the DSHS-CSHCN Services Program. The filing and appeal deadlines are described in 25 TAC §38.10 and §38.13 and in this manual.

Refer to: Section 5.1.5, "Claims Filing Deadlines" for additional information.

Additional information requested by the DSHS-CSHCN Services Program must be returned to DSHS-CSHCN Services Program within 30 calendar days of the date of the letter from the DSHS-CSHCN Services Program. If the information is not received within 30 calendar days, the case is closed.

Refer to: The Fair Hearing Request and Administrative Review Deadline Calendars (2008, 2009, and 2010) beginning on page 7-12.