7 Appeals and Administrative Review

7.1 Appeals 7-2

7.2 Authorization and Prior Authorization Denials 7-2

7.2.1 Administrative Review for Authorization or Prior Authorization Denials 7-2

7.2.2 Fair Hearing Requests for Authorizations or Prior Authorizations 7-3

7.3 Claim Appeals 7-3

7.3.1 Electronic Appeal Submission 7-3

7.3.1.1 Advantages of Electronic Appeal Submission 7-4

7.3.1.2 Disallowed Electronic Appeals 7-4

7.3.1.3 Electronic Rejections 7-4

7.3.2 AIS Claim Correction and Resubmission (Appeals) 7-5

7.3.3 Paper Appeals 7-5

7.3.3.1 Total Billed Amount Changes 7-6

7.3.4 Appeals Submitted Incorrectly 7-6

7.3.5 Administrative Review for Claims 7-6

7.3.5.1 Administrative Review Requirements 7-7

7.3.6 Fair Hearing for Claims 7-8

7.3.7 National Correct Coding Initiative (NCCI) Claims Appeals 7-8

7.4 Provider Enrollment Appeals 7-9

7.5 TMHP-CSHCN Services Program Contact Center 7-9

7.6 Authorization and Filing Deadline Calendar for 2012 7-9

7.7 Authorization and Filing Deadline Calendar for 2013 7-9