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Appeals
6.1 Appeal Methods 6-2
6.1.1 Electronic Appeal Submission 6-2
6.1.1.1 Advantages of Electronic Appeal Submission 6-2
6.1.1.2 Allowed Electronic Appeals 6-2
6.1.1.3 Disallowed Electronic Appeals 6-2
6.1.2 Automated Inquiry System Appeals 6-3
6.1.3 Automated Inquiry System Automated Appeals Guide 6-3
6.1.4 Paper Appeals 6-3
6.1.4.1 Texas Medicaid Fee-for-Service DRG Adjustment Appeal 6-4
6.1.4.2 Medical Necessity Denial Appeals 6-4
6.1.4.3 Other Insurance Appeals 6-4
6.1.5 Appeals Submitted Incorrectly 6-4
6.2 Refunds to TMHP Resulting from Other Insurance Payments 6-4
6.3 Appeals to HHSC Texas Medicaid Fee-for-Service and PCCM 6-5
6.3.1 Administrative Claim Appeals 6-5
6.3.1.1 Requirements for Exception Requests 6-6
6.3.1.2 Exceptions to the 95-Day Filing Deadline 6-6
6.3.1.3 Exceptions to the 120-day Appeal Deadline 6-7
6.3.1.4 Exceptions to the 24-Month Payment Deadline 6-8
6.3.2 Medical Necessity Appeals 6-8
6.3.3 PCCM DRG Adjustment Appeals 6-8
6.3.4 Utilization Review Appeals 6-9
6.3.4.1 Admission Denials, Continued Stay Denials for TEFRA Hospitals,
DRG Revisions, and Cost/Day Outlier Denials 6-9
6.3.4.2 Final Technical Denials 6-10
6.3.5 Provider Complaints 6-10
6.3.6 Complaints to HHSC-Texas Medicaid Fee-for-Service and PCCM 6-11
6.3.7 Complaints to HHSC-HMO Services 6-11
6.3.8 Complaints to DSHS-BHO Services 6-12
6.4 Cost Report Settlement Appeal Process 6-13
6.4.1 Appeals to TMHP Medicaid Audit 6-13
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