TMPPM 2011 > Volume 1, General Information > Section 8: Managed Care > PCCM > Provider Complaints and Appeals > Authorization Appeals

8.6.20.3 Authorization Appeals

A denial is issued when an authorization or update to an existing request by a physician or a facility is not approved by the TMHP Medical Director or designee.

A medical necessity denial is issued when the documentation provided fails to support the need for requested service or the client's condition or service requested does not warrant the level or location of care the provider requested.

A denial is also issued when the provider has failed to comply with PCCM policies and procedures. These include failure to:

•Notify of an inpatient stay.

•Obtain authorization for an elective or scheduled service prior to the delivery of service.

A denial may also be issued if:

•The provider or the location of service is not within the network.

•The patient is no longer eligible for coverage.

•The service is not a benefit of Texas Medicaid.

The appeals or authorization reconsideration process affords the provider the opportunity to dispute a denial and explain or justify the original request.

Refer to: Section 7: Appeals (Vol. 1, General Information).