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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.3 Appeals to HHSC Texas Medicaid Fee-for-Service : 7.3.1 Administrative Claim Appeals : 7.3.1.1 Requirements for Exception Requests

7.3.1.1
HHSC Claims Administrator Operations Management makes the final decision on whether claims fall within one of the exceptions to the 95-day or 120-day filing deadlines.
Providers must submit the following documentation for all exception requests:
Adequate back-up documentation must accompany the exception request. Failure to provide adequate documentation results in the case being closed. Providers are notified of the reason for denial.
Additional claims cannot be added to an exception request after the exception request has been completed by HHSC. Additional claims must be submitted as a separate request and must include all required documentation. Information from a previous request will not be linked by HHSC to process additional claims.
All exception requests must include an affidavit or statement from the provider stating the details of the cause for the delay, the exception being requested, and verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider’s employee or agent. This affidavit or statement must be made by the person with personal knowledge of the facts.
Multiple requests submitted simultaneously must be sorted by provider identifier first, and then alphabetically by client name. The orderly submission of exception requests facilitates the review process. Exception requests are returned to the provider if not submitted in the required format.
HHSC may request additional information which must be received within 21 calendar days from the date of the letter from HHSC. If the information is not received within 21 calendar days, the case will remain closed.
HHSC notifies providers about the outcome of the case upon completion of an exception request review.

Texas Medicaid & Healthcare Partnership
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