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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.1 Appeal Methods : 7.1.1 Electronic Appeal Submission : 7.1.1.2 Disallowed Electronic Appeals

7.1.1.2
The following claims may not be appealed electronically:
Claims listed as pending or in process with explanation of pending status (EOPS) messages.
Claims denied as past filing deadline except when retroactive eligibility deadlines apply.
Claims denied as past the payment deadline.
Exception:
Inpatient hospital claims denied for lack of a Hysterectomy Acknowledgment Statement or a Sterilization Consent Form may be appealed electronically if the requested form has been faxed according to the instructions in the Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information on the TMHP website at www.tmhp.com.
Resubmission of TMHP Electronic Data Interchange (EDI) Rejections
TMHP EDI transactions that fail HIPAA edits will be rejected, and the submitter will receive a 277CA claim response file. The 277CA claims response file lists activity by submitter, provider, and payer.
The 277CA claims response file includes member identifier, patient last name and first initial, patient control number (PCN), type of bill or place of service, charge, transaction from and to dates, receipt date, rejection code, and rejection description.
Providers must send the batch ID, PCN, date of service, transaction from and to dates, receipt date, and rejection codes from the 277CA claims response file to TMHP when appealing denied claims.
The batch ID is located in the file name of the returned 277CA claims response, and not within the file. Providers must include the batch ID in all electronic response files submitted to TMHP for appeals to denied claims. Handwritten batch IDs are not acceptable for submission to TMHP. Providers who cannot identify or retrieve the batch ID from the 277CA claims response file name should contact the clearinghouse or vendor to have the filename included in the response document. If not, the provider must request a copy of the response file that contains the filename from the clearinghouse.
Providers who receive a rejection on the 277CA claims response file may resubmit an electronic claim within 95 days of the date of service.
A paper appeal may also be submitted with a copy of the response document within 120 days of the 277CA claims response file rejection to meet the filing deadline. A copy of the electronic response file rejection to include the batch ID must accompany each corrected claim that is submitted on paper.

Texas Medicaid & Healthcare Partnership
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