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7.3 Administrative Review
After the provider has exhausted all aspects of the TMHP appeals process for the entire claim, the provider may submit a request for an administrative review to the DSHS-CSHCN Services Program.
A request for an administrative review can be submitted to the DSHS-CSHCN Services Program only after the claim has been fully adjudicated and meets all three of the following conditions:
| a) |
The claim has been denied or adjusted by TMHP. |
| b) |
The claim has been appealed as a first-level appeal to TMHP. |
| c) |
The first level appeal has been denied again for the same reasons by TMHP. |
Administrative review requests are submitted by the provider to the DSHS-CSHCN Services Program.
All providers must submit requests for an administrative review within 30 days of the date TMHP denied the appeal. Requests for an administrative review and all supporting documentation must be submitted by mail or fax to:
CSHCN Services Program-Administrative Review
Purchased Health Services Unit, MC-1938
Texas Department of State Health Services
PO Box 149347
Austin, TX 78714-9347
Fax: 1-800-441-5133
TMHP may be required to gather information related to the original claim and the first-level appeal. The DSHS-CSHCN Services Program is the sole adjudicator of the administrative review.
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