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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 7: Appeals : 7.1 Appeal Methods : 7.1.5 Paper Appeals

7.1.5
Claim appeal requests that cannot be appealed electronically or by using AIS may be appealed on paper. Completed claim forms are not required to be submitted with paper appeals. Providers who submit paper appeals must clearly document on the attached R&S Report the information that is being appealed and identify the claim being appealed.
If a provider determines that a claim cannot be appealed electronically or through AIS, the claim may be appealed on paper by completing the following:
1)
Submit a copy of the R&S Report page on which the claim is paid or denied. A copy of other official notification from TMHP may also be submitted.
2)
3)
Circle only one claim per R&S Report page.
4)
5)
6)
Attach a copy of any supporting medical documentation that is required or has been requested by TMHP. Supporting documentation must be on a separate page and not copied on the opposite side of the R&S Report.
Note:
It is strongly recommended that providers submitting paper appeals retain a copy of the documentation being sent. It also is recommended that paper documentation be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which is particularly important if it is necessary to prove that the 120‑day appeals deadline has been met. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, date of service (DOS), and a signed claim copy. The provider may need to keep such proof regarding multiple claims submissions if the provider identifier is pending.
Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG assignment/adjustment must be submitted on paper with the appropriate documentation.
Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims) to the following address:
Texas Medicaid & Healthcare Partnership
Appeals/Adjustments
PO Box 200645
Austin, TX 78720‑0645
Exception:
Hospitals appealing HHSC OIG UR Unit final technical denials, admission denials, DRG revisions, continued-stay denials for Tax Equity and Fiscal Responsibility Act (of 1982) (TEFRA) Hospitals, or cost/day outliers must appeal to HHSC at the following address:
Texas Health and Human Services Commission
Medical and UR Appeals, H‑230
PO Box 85200
Austin, TX 78708‑5200
All other provider fields on the claim forms (referring, facility, admitting, operating, and other) require only an NPI.
Providers that choose to appeal the claim with NPI information must continue submitting both a TPI and an NPI until the claim is finalized.

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