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6.3 Appeals to HHSC Fee-for-Service and PCCM
6.3.1 Administrative Claim Appeals
An administrative appeal is a request for review of (not a hearing on) claims denied by TMHP or claims processing entity for technical and non-medical reasons. There are two types of administrative appeals:
1) |
Exception requests to the 95-day claim filing deadline. A provider's formal written request for review of (not a hearing on) a claim that is denied or adjusted by TMHP for failure to meet the 95-day claim filing deadline. This exception should meet the qualifications for one of the five exceptions listed on page 6-5 and should be submitted directly to HHSC. |
2) |
Standard Administrative Appeal. A provider's formal written request for review of (not a hearing on) a claim or prior-authorization that is denied by TMHP for technical and/or non-medical reasons. |
An administrative claims appeal is a request for a review as defined in Title 1 Texas Administrative Code (TAC) §354.2201(2).
An administrative appeal must be:
• Submitted in writing to HHSC Claims Administrator Contract Management by the provider delivering the service or claiming reimbursement for the service.
•Received by HHSC Claims Administrator Contract Management after the appeals process with TMHP or the claims processing entity has been exhausted, and must contain evidence of appeal dispositions from TMHP or the claims processing entity:
•All correspondence and documentation from the provider to TMHP or the claims processing entity including copies of supporting documentation submitted during the appeal process.
•All correspondence from TMHP or the claims processing entity to the provider including TMHP's final decision letter or such from the claims processing entity.
•Complete and contain all of the information necessary for consideration and determination by HHSC Claims Administrator Contract Management to include the following:
•A written explanation specifying the reason/request for appealing the claim.
•Supporting documentation for the request.
•All R&S reports identifying the claims/services in question.
•Identification of the incorrect information and the corrected information that is to be used to appeal the claim.
•A copy of the original claim, if available. Claim copies are helpful when the appeal involves medical policy or procedure coding issues. Also provide a corrected signed claim.
•A copy of supporting medical documentation that is necessary or requested by TMHP.
•Provider's internal notes and logs when pertinent (cannot be used as proof of timely filing).
•Memos from the state, TMHP, or claims processing entity indicating any problems, policy changes, or claims processing discrepancies that may be relevant to the appeal.
•Other documents, such as receipts (i.e., certified mail along with a detailed listing of the claims enclosed), in-service notes, minutes from meetings, etc., if relevant to the appeals. Receipts can be helpful when the issue is late filing.
•Received by HHSC Claims Administrator Contract Management within 120 days from the date of disposition by TMHP or the claims processing entity as evidenced by the R&S sent to providers.
Providers that have submitted their claims electronically must identify the batch submission ID with the date on the electronic claims report. This report must indicate the TMHP assigned batch ID. In addition, this report must include the individual claim that is being appealed. This required information constitutes proof of timely filing.
Note: Only reports accepted/rejected from TMHP or the claims processing entity to the vendor will be honored unless the provider is a direct submitter (TexMedConnect or TDHconnect). Office notes indicating claims were submitted on time or personal screen prints of claim submissions are not considered proof of timely filing.
HHSC Claims Administrator Contract Management only reviews appeals that are received within 18 months from the date-of-service. All claims must be paid within 24 months from the date of service as outlined in 1 TAC §354.1003.
Providers must adhere to all filing and appeal deadlines for an appeal to be reviewed by HHSC Claims Administrator Contract Management. The filing and appeal deadlines are described in 1 TAC §354.1003.
Additional information requested by HHSC Claims Administrator Contract Management must be returned to HHSC Claims Administrator Contract Management within 21 calendar days from the date of the letter from HHSC Claims Administrator Contract Management. If the information is not received within 21 calendar days, the case is closed.
A determination made by HHSC Claims Administrator Contract Management is the final decision for claim appeals. No additional consideration is available. Therefore, ensure that all documents pertinent to the appeal are submitted. New evidence is required for an additional appeal to HHSC Claims Administrator Contract Management.
Providers mail appeal requests to the following address:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
PO Box 204077
Austin, Texas 78720-4077
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