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6.3.4 Utilization Review Appeals
Hospitals may appeal adverse UR decisions made by the HHSC OIG UR department to the HHSC Medical and UR Appeals Unit. The written appeal request must be received by the Medical and UR Appeals Unit within 120 days of the date of the original HHSC OIG UR decision letter. If the request is not received within 120 days, the appeal is not conducted, and the HHSC OIG UR decision is considered final. Any claim the facility may have to the Medicaid funds at issue are barred. Extensions of time are not granted for filing the written appeal request, submission of the complete medical record, or the original properly completed notarized affidavit in the format approved by HHSC. Procedures and specific requirements for appealing these decisions can be found in the sections below.
Hospitals may appeal adverse HHSC OIG UR determinations to the following address:
Texas Health and Human Services Commission
Medical and UR Appeals, H-230
PO Box 85200
Austin, TX 78708-5200
Note: UR Admission Denials, Continued Stay Denials, DRG Revisions, Cost/Day Outlier Denials or Technical Denials issued by Medicaid managed care organizations (MCOs) must be appealed to the appropriate health plan. The HHSC Medical and UR Appeals Unit does not have the authority to manage these appeals.
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