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19.24.2 Dental Claims Appeal Information
Providers may use three methods to appeal Medicaid claims to TMHP: telephone (AIS), paper, or electronically.
All appeals of denied claims or requests for adjustments on paid claims must be received by TMHP within 120 days from the date of disposition of the R&S report on which the claim appears. If the 120-day appeal deadline falls on a weekend or TMHP-recognized holiday, the deadline will be extended to the next business day.
The following claims must be appealed on paper; they cannot be appealed either electronically or by using AIS:
• Claims listed on the R&S report as incomplete. These include claims missing required information, such as the signature on the claim. Resubmit the corrected claim with a copy of the R&S report for reprocessing to the TMHP physical address, Attn: Inquiry Control Unit.
•Claims requiring supporting documentation (for example, operative reports, dental records, dental radiographs, or narratives).
•Claims listed as pending or in process with an explanation of pending status (EOPS) message. These claims have not been finalized at the time the R&S report was generated; therefore, they cannot be appealed.
•Claims denied as past filing deadline. The provider must provide a copy of a previous R&S report as proof the claim was received by TMHP within the filing deadline.
To appeal in writing:
If a claim cannot be appealed electronically or by telephone, appeal the claim on paper by completing the following steps:
1) |
Provide a copy of the R&S report page where the claim is reported. |
2) |
Circle one claim per R&S report page. |
3) |
Identify the information that was incorrectly provided and note the correct information that should be used to appeal the claim. If necessary, specify the reason for appealing the claim. |
4) |
Attach radiographs or other necessary supporting documentation. |
5) |
If available, attach a copy of the original claim. Claim copies are helpful when the appeal involves dental policy or procedure coding issues. |
6) |
Do not copy supporting documentation on the opposite side of the R&S report. |
7) |
It is strongly recommended that providers submitting paper appeals retain a copy of the documentation being sent. It is also recommended that paper documentation be sent via certified mail with a return receipt requested to establish TMHP's receipt of the claim and the date the claim was received. The provider is urged to retain copies of multiple claim submissions if the Medicaid provider identifier is pending. |
Note: Providers have 95 days from the issuance of the provider identifier to submit claims.
8) |
Submit the paper appeal with supporting documentation and any radiographs and adjustment requests to the following address: |
Texas Medicaid & Healthcare Partnership
Inquiry Control Unit
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
To appeal by telephone:
1) |
Contact the Dental Line at 1-800-568-2460. |
2) |
For each claim in question, have the R&S report listing the claim and any supporting documents readily available. |
3) |
Identify the claim submitted for appeal. The internal control number (ICN) will be requested. |
4) |
Supply the information necessary to correct the claim, such as the missing tooth number or letter, the corrected procedure code, surface ID, or Medicaid number. |
The appeal will appear as finalized or pending on the following week's R&S report.
Providers may also appeal electronically.
Electronic appeal submission is a method of submitting Texas Medicaid appeals using a personal computer (PC). The electronic appeals feature can be accessed by a business organization bridging directly into the TMHP EDl Gateway or by using TexMedConnect or TDHconnect software. For additional information, contact the TMHP EDI Help Desk at 1-888-863-3638.
Electronic appeals can increase accuracy of claims processing, resulting in a more efficient case flow to the provider:
•Download and printout capabilities help maintain audit trails for the provider.
•Appeal submission windows can be automatically filled in with electronic R&S report information, thereby reducing data entry time.
Electronic appeals submission is available to business organizations (for example, billing organizations, vendors, and clearinghouses) and interfaces directly with TMHP EDI or through TexMedConnect or TDHconnect software.
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