|
7.7.17.9 Appeals of Denied Requests for Authorization
If an authorization request for admission or service is denied, the requesting provider will receive a denial letter from the PCCM Prior Authorization Department. Where appropriate, the hospital or facility involved is also notified of the denial.
Requests for reconsideration for prior authorizations for inpatient services are subject to the following steps:
1) |
Provider submits a request for prior authorization to the prior authorization unit and obtains the authorization or a denial for the authorization from TMHP. |
2) |
If the provider is not satisfied with the results of step 1, they can appeal step 1 by submitting additional information/documentation to TMHP. This step can be repeated multiple times as long as the provider is submitting additional information/documentation. |
3) |
If the provider is not satisfied with the outcome determined by TMHP in step 2 and no additional information is available to submit to TMHP, the provider may submit a request for reconsideration to HHSC (only if step 1 is complete and step 2 is thoroughly exhausted). |
These steps are applicable prior to filing the claim. Filing deadlines should be taken into consideration, and HHSC will not review if steps 1 and 2 were not followed.
Refer to: "Appeals" and "Authorization Appeals" .
|
