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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 7: Appeals

Section 7: Appeals
7.1 Appeal Methods 7-2
7.1.1 Electronic Appeal Submission 7-2
7.1.1.1 Advantages of Electronic Appeal Submission 7-3
7.1.1.2 Disallowed Electronic Appeals 7-3
7.1.2 Resubmission of TMHP Electronic Data Interchange (EDI) Rejections 7-3
7.1.3 Automated Inquiry System (AIS) Appeals 7-3
7.1.4 Automated Inquiry System Automated Appeals Guide 7-4
7.1.5 Paper Appeals 7-4
7.1.5.1 Texas Medicaid Fee-for-Service DRG Adjustment Appeal 7-5
7.1.5.2 Medical Necessity Denial Appeals 7-6
7.1.5.3 Other Insurance Appeals 7-6
7.1.6 Appeals Submitted Incorrectly 7-6
7.2 Refunds to TMHP 7-6
7.2.1 Refunds Resulting from Other Insurance Payments 7-7
7.3 Appeals to HHSC Texas Medicaid Fee-for-Service 7-8
7.3.1 Administrative Claim Appeals 7-8
7.3.1.1 Requirements for Exception Requests 7-9
7.3.1.2 Exceptions to the 95‑Day Filing Deadline 7-10
7.3.1.3 Exceptions to the 120‑day Appeal Deadline 7-11
7.3.1.4 Exceptions to the 24‑Month Payment Deadline 7-12
7.3.2 Medical Necessity Appeals 7-12
7.3.3 Utilization Review Appeals 7-12
7.3.3.1 Admission Denials, Continued Stay Denials for TEFRA Hospitals,
DRG Revisions, and Cost/Day Outlier Denials 7-13
7.3.3.2 Final Technical Denials 7-14
7.3.4 Provider Complaints 7-14
7.3.4.1 Provider Complaint Policy 7-15
7.3.4.2 Provider Complaint Process 7-15
7.3.4.3 Complaints to HHSC—Texas Medicaid Fee-for-Service 7-15
7.4 Cost Report Settlement Appeal Process 7-16
7.4.1 Appeals to TMHP Medicaid Audit 7-17
7.5 Forms 7-17
7.1 Business Records Affidavit Form 7-18
7.2 Texas Medicaid Refund Information Form 7-19
7.3 Credit Balance Refund Worksheet 7-20

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.