|
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 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 6-4
6.3 Appeals to HHSC Fee-for-Service and PCCM 6-4
6.3.1 Administrative Claim Appeals 6-4
6.3.1.1 Exceptions to the 95-Day Filing Deadline 6-5
6.3.1.2 Exceptions to the 120-day Appeal Deadline 6-7
6.3.1.3 Exceptions to the 24-Month Payment Deadline 6-7
6.3.2 Medical Necessity Appeals 6-8
6.3.3 PCCM DRG Adjustment Appeals 6-8
6.3.4 Utilization Review Appeals 6-8
6.3.4.1 Admission Denials, Continued Stay Denials, DRG Revisions,
and Cost/Day Outlier Denials 6-8
6.3.4.2 Final Technical Denials 6-9
6.3.5 Complaints to HHSC-Fee-for-Service and PCCM 6-9
6.3.6 Complaints to HHSC-HMO Services 6-10
6.4 Cost Report Settlement Appeal Process 6-10
6.4.1 Appeals to TMHP Medicaid Audit 6-11
|
|
