7.3.2 AIS Claim Correction and Resubmission (Appeals)

Telephone resubmissions or appeals may be entered through AIS using the keypad of a touch tone telephone. Providers may submit up to 3 field corrections per claim and 15 appeals per call. If invalid information is entered three times during any step, the call is transferred to a contact center representative for assistance.

For more information about how to correct and resubmit claims using AIS, providers may obtain a CSHCN Services Program AIS User Guide online at www.tmhp.com or by calling 1‑800‑568‑2413.

Providers may submit appeals through AIS to correct claims that were denied for the following:

•	Beginning date of service

•	Billing, performing, or referring provider identification numbers

•	Client number

•	Date of birth

•	Date of onset

•	Ending date of service

•	Place of service (POS)

•	Prior authorization number (PAN)

•	Quantity billed

•	X-ray date

•	Type of service (TOS)

The following may not be appealed through AIS, and providers must appeal these denied claims on paper:

•	Incomplete claims listed on the R&S Report in the “Claims - Paid or Denied” section

•	Claims listed on the R&S Report with $0 allowed and $0 paid

•	Claims that require supporting documentation (e.g., operative report, medical records)

•	Procedure code, modifier, or diagnosis code

•	Claims listed as pending or in process with Explanation of Pending Status (EOPS) messages

•	Claims denied as past filing deadline except when retroactive eligibility deadlines apply

•	Claims denied as past the payment deadline

•	Inpatient hospital claims that require supporting documentation

•	Third-Party Liability (TPL) and other insurance