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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals

Section 7: Appeals
Table of Contents
7.1 Appeal Methods 3
7.1.1 Electronic Appeal Submission 3
7.1.1.1 Advantages of Electronic Appeal Submission 4
7.1.1.2 Disallowed Electronic Appeals 4
7.1.2 Automated Inquiry System (AIS) Appeals 5
7.1.3 Automated Inquiry System Automated Appeals Guide 6
7.1.4 Paper Appeals 6
7.1.4.1 Texas Medicaid Fee-for-Service DRG Adjustment Appeal 7
7.1.4.2 Medical Necessity Denial Appeals 7
7.1.4.3 Other Insurance Appeals 7
7.1.5 Appeals Submitted Incorrectly 7
7.2 * Refunds to TMHP 8
7.3 Appeals to HHSC Texas Medicaid Fee-for-Service 8
7.3.1 Administrative Claim Appeals 8
7.3.1.1 Requirements for Exception Requests 10
7.3.1.2 Exceptions to the 95‑Day Filing Deadline 11
7.3.1.3 Exceptions to the 120‑day Appeal Deadline 12
7.3.1.4 Exceptions to the 24‑Month Payment Deadline 12
7.3.2 Medical Necessity Appeals 13
7.3.3 Utilization Review Appeals 13
7.3.3.1 Admission Denials, Continued Stay Denials for TEFRA Hospitals, DRG Revisions, and Cost/Day Outlier Denials 13
7.3.3.2 Final Technical Denials 15
7.3.4 Provider Complaints 15
7.3.4.1 Provider Complaint Policy 16
7.3.4.2 Provider Complaint Process 16
7.3.4.3 Complaints to HHSC—Texas Medicaid Fee-for-Service 16
7.4 Cost Report Settlement Appeal Process 17
7.4.1 Appeals to TMHP Medicaid Audit 17
7.5 Forms 18
 

Texas Medicaid & Healthcare Partnership
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