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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.1 Appeal Methods

7.1
An appeal is a request for reconsideration of a previously dispositioned claim.
Providers may use three methods to appeal Medicaid fee-for-service and carve-out service claims to Texas Medicaid & Healthcare Partnership (TMHP): electronic, Automated Inquiry System (AIS), or paper.
TMHP must receive all appeals of denied claims and requests for adjustments on paid claims within 120 days from the date of disposition of the Remittance and Status (R&S) Report on which that claim appears. If the 120‑day appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day.
Standard administrative requests and medical appeals must be sent first to TMHP or the claims processing entity as a first-level appeal. After the provider has exhausted all aspects of the appeals process for the entire claim, the provider may submit a second-level appeal to HHSC.
1)
A first-level appeal is a provider’s initial standard administrative or medical appeal of a claim that has been denied or adjusted by TMHP. This appeal is submitted by the provider directly to TMHP for adjudication and must contain all required information to be considered.
2)
This appeal is submitted by the provider to HHSC, which may subsequently require TMHP to gather information related to the original claim and the first-level appeal. HHSC is the sole adjudicator of this final appeal.
All providers must submit second-level administrative appeals and exceptions to the 95‑day filing deadline appeals to the following address:
Texas Health and Human Services Commission
HHSC Claims Administrator Operations Management
Mail Code 91X
PO BOX 204077
Austin, Texas 78720‑4077
TMHP is not responsible for managing appeals resulting from utilization review (UR) decisions by the HHSC Office of Inspector General (OIG) UR Unit. These must be submitted to HHSC Medical and UR Appeals.
Note:
Appeals for managed care claims must be submitted to the managed care organization (MCO) or dental plan that administers the client’s managed care benefits. The only managed care appeals administered by TMHP are those for carve-out services.
Refer to:
The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for additional information about managed care appeals.

Texas Medicaid & Healthcare Partnership
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