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6.1.4 Paper Appeals
After determining a claim cannot be appealed electronically or through AIS, appeal the claim on paper by completing the following steps:
1) |
Copy the R&S page where the claim is paid or denied. A copy of other official notification from TMHP may also be submitted. |
2) |
Circle one claim per R&S page. |
3) |
Identify the reason for the appeal. |
4) |
If applicable, indicate the incorrect information on the claim, and provide the corrected information that should be used to appeal it. |
5) |
Attach a copy of any supporting medical documentation that is required or has been requested by TMHP. |
6) |
Attach a completed claim form. |
Reminder: Do not copy supporting documentation on the opposite side of the R&S report. Note: It is strongly recommended that providers submitting paper appeals retain a copy of the documentation being sent. It also is recommended that paper documentation be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which 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 listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. The provider may need to keep such proof regarding multiple claims submissions if the provider identifier is pending.
Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG assignment/adjustment must be submitted on paper with the appropriate documentation.
Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims) to the following address:
Texas Medicaid & Healthcare Partnership
Appeals/Adjustments
PO Box 200645
Austin, TX 78720-0645
Exception: Hospitals appealing HHSC OIG UR Department final technical denials, admission denials, DRG revisions, continued-stay denials, or cost/day outliers must appeal to HHSC at the following address:
Texas Health and Human Services Commission
Medical and UR Appeals, H-230
PO Box 85200
Austin, TX 78708-5200
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