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6.4.1 Appeals to TMHP Medicaid Audit
A provider's request to appeal his or her NPR must do the following:
• Identify specific individual items in TMHP Medicaid Audit's determination with which the provider disagrees.
•Give the reasons the provider believes these are incorrect.
•Identify the amount in controversy for each item and provide a calculation of that amount.
The appeal may include any materials the provider believes will support its position.
TMHP Medicaid Audit completes a desk review of the appeal within six months of the date of receipt of complete documentation supporting the appeal. TMHP does the following:
•Review the materials submitted by the provider.
•Inform the provider if it appears that the request for an appeal was not timely or the amount of controversy is not at least $1,000.
•Review the record that formed the basis for the determination of the total payment due to the provider.
•Attempt to resolve as many points in controversy as possible with the provider and inform him or her in writing the issues that have been resolved and those that the provider may appeal to HHSC.
•Ensure all available documentation in support of the provider or TMHP Medicaid Audit is part of the record.
To appeal to TMHP Medicaid Audit, send the written notice to the following address within 120 days of receipt of the NPR letter to the following address:
Texas Medicaid & Healthcare Partnership
Medicaid Audit Operations Director
PO Box 200345
Austin, TX 78720-0345
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