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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.1 Appeal Methods : 7.1.4 Paper Appeals : 7.1.4.2 Medical Necessity Denial Appeals

7.1.4.2
Appeals of denials relating to medical necessity decisions made for all medical services with the exception of HHSC Inpatient UR cases may be submitted for further review if providers find denials are inappropriate. All necessary documentation must accompany the request for review. Incomplete appeals and adjustment requests are denied by TMHP with an explanation of benefits (EOB) code requesting additional information.
TMHP reviews each appeal (DRG adjustment and medical necessity) and forwards written notice of final action in the form of a letter or an adjustment transaction on the R&S Report.

Texas Medicaid & Healthcare Partnership
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