7.3.3 Paper Appeals

If a claim cannot be appealed electronically or by using AIS, providers may appeal the claim on paper by completing the following:

1)	Submit a copy of the R&S page on which the claim is paid or denied or other official notification from TMHP (i.e., TMHP letters attached to returned claims).

2)	Submit one copy of the R&S Report page for each claim appealed.

3)	Circle only one claim per R&S page.

4)	Indicate the reason for the appeal.

5)	If applicable, indicate the incorrect information and provide the correct information that should be used to appeal the claim.

6)	Attach a copy of any supporting documentation that is necessary or requested by TMHP. Supporting documentation must be on a separate page.

Note: Completed claim forms are not required to be submitted with paper appeals. Providers who submit paper appeals must clearly document on the R&S Report what information is being appealed and must identify the claim being appealed.

Reminder: Do not copy supporting documentation on the opposite side of the R&S Report.

Paper appeals must be submitted to the following address:

Texas Medicaid & Healthcare Partnership
Attn: CSHCN Services Program Appeals, MC-A11
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727

Providers may not request reconsideration or appeal of the following:

•	Claims appearing in the “Pending Claims” section of the R&S Report. Providers cannot resubmit or appeal a claim that has not appeared as a paid or denied claim.

•	Incomplete claims appearing in the “Claims - Paid or Denied” section of the R&S Report. Incomplete claims appear with one or more EOB code(s). Providers must correct the information and submit a new claim with the R&S Report within 120 days of the date on the R&S Report.

Important: It is strongly recommended that providers who submit paper appeals retain a copy of the documentation they send. It also is recommended that paper documentation be sent by certified mail with a return receipt requested. This documentation and a detailed list of the claims that were enclosed provides proof that the claims were received by TMHP. This is particularly important if it is necessary to prove that the 120‑day appeals deadline has been met. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed list. The provider may need to keep such proof for all claims submissions, if their CSHCN Services Program provider identifier is pending.