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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 7: Appeals : 7.3 Appeals to HHSC Texas Medicaid Fee-for-Service

7.3 Appeals to HHSC Texas Medicaid Fee-for-Service
7.3.1
An administrative appeal is a request for review of (not a hearing on) claims that are denied by TMHP or claims processing entity for technical and nonmedical reasons. There are two types of administrative appeals:
Exception requests to the 95day filing deadline or 120-day appeal deadline. A provider’s formal written request for review of (not a hearing on) a claim that is denied or adjusted by TMHP for failure to meet the 95‑day filing deadline or 120-day appeal deadline. Exception requests to the 95-day filing deadline should meet one of the five exceptions in subsection 7.3.1.2, “Exceptions to the 95‑Day Filing Deadline” in this section. Exceptions to the 120-day appeal deadline should meet one of the situations in subsection 7.3.1.3, “Exceptions to the 120‑day Appeal Deadline” in this section.
Standard Administrative Appeal. A provider’s formal written request for review of (not a hearing on) a claim or prior-authorization that is denied by TMHP for technical or non-medical reasons.
An administrative claims appeal is a request for a review as defined in Title 1 TAC §354.2201(2).
An administrative appeal must be:
Received by HHSC Claims Administrator Contract Management after the appeals process with TMHP or the claims processing entity has been exhausted, and must contain evidence of appeal dispositions from TMHP or the claims processing entity:
All correspondence and documentation from the provider to TMHP or the claims processing entity including copies of supporting documentation submitted during the appeal process.
All correspondence from TMHP or the claims processing entity to the provider including TMHP’s final decision letter or such from the claims processing entity.
Complete and contain all of the information necessary for consideration and determination by HHSC Claims Administrator Contract Management to include the following:
A copy of the original claim, if available. Claim copies are helpful when the appeal involves medical policy or procedure coding issues. Also provide a corrected signed claim.
Memos from HHSC, TMHP, or claims processing entity indicating any problems, policy changes, or claims processing discrepancies that may be relevant to the appeal.
Other documents, such as receipts (i.e., certified mail along with a detailed listing of the claims enclosed), in-service notes, minutes from meetings, if relevant to the appeals. Receipts can be helpful when the issue is late filing.
Received by HHSC Claims Administrator Contract Management within 120 days from the date of disposition by TMHP or the claims processing entity as evidenced by the weekly R&S Report.
Providers who have submitted their claims electronically must identify the batch submission ID with the date on the electronic claims report. This report must indicate the TMHP assigned batch ID. In addition, this report must include the individual claim that is being appealed. The claim information on the batch report, including date of service and billed amount, must match the information on the claim that is being appealed. This required information constitutes proof of timely filing.
Note:
Only reports accepted or rejected from TMHP or the claims processing entity to the vendor will be honored unless the provider is a direct submitter (TexMedConnect). Office notes indicating claims were submitted on time or personal screen prints of claim submissions are not considered proof of timely filing.
HHSC Claims Administrator Contract Management only reviews appeals that are received within 18 months from the DOS. All claims must be paid within 24 months from the DOS as outlined in 1 TAC §354.1003.
Providers must adhere to all filing and appeal deadlines for an appeal to be reviewed by HHSC Claims Administrator Contract Management. The filing and appeal deadlines are described in 1 TAC §354.1003.
Additional information requested by HHSC Claims Administrator Contract Management must be returned to HHSC Claims Administrator Contract Management within 21 calendar days from the date of the letter from HHSC Claims Administrator Contract Management. If the information is not received within 21 calendar days, the case is closed.
A determination made by HHSC Claims Administrator Contract Management is the final decision for claim appeals. No additional consideration is available. Therefore, ensure that all documents pertinent to the appeal are submitted. New evidence is required for an additional appeal to HHSC Claims Administrator Contract Management.
Mail appeal requests to the following address:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
PO Box 204077
Austin, Texas 78720‑4077

Texas Medicaid & Healthcare Partnership
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