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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 : 7.3.1.3 Exceptions to the 120‑day Appeal Deadline

7.3.1.3
Exceptions to the 120‑day Appeal Deadline
HHSC must receive a written exception request within 120 days of TMHP’s final action. HHSC shall consider exceptions to the 120-day appeal deadline for the situations listed below. This is a one-time exception request; therefore, all claims that are to be considered within the request for an exception must accompany the request. Claims submitted after HHSC’s determination has been made for the exception will be denied consideration because they were not included in the original request.
An exception request must be received by HHSC within 18 months from the date of service to be considered. This requirement will be waived for the exceptions listed in the following bullets (b) and (c), as well as the situation listed under “Exceptions to the 24‑month deadline.”
The following exceptions to the 120‑day appeal deadline are considered if the criteria in the previous bullet is met and there is evidence to support one of the bullets below:
(a) Errors made by a third party payor that were outside the control of the provider. The provider must submit a statement outlining the details of the cause for the error, the exception being requested, and verification that the error was not caused by neglect, indifference, or lack of diligence of the provider, the provider’s employee, or agent. This affidavit or statement should be made by the person with personal knowledge of the facts. In lieu of the above affidavit or statement from the provider, the provider may obtain an affidavit or statement from the third party payor including the same information, and provide this to HHSC as part of the request for appeal.
(b) Errors made by the reimbursement entity that were outside the control of the provider. The provider must submit a statement from the original payor outlining the details of the cause of the error, the exception being requested, and verification that the error was not caused by neglect, indifference, or lack of diligence on the part of the provider, the provider’s employee, or agent. In lieu of the above reimbursement entity’s statement, the provider may submit a statement including the same information and provide this to HHSC as part of the request for appeal.
(c) Claims were adjudicated, but an error in the claim’s processing was identified after the 120‑day appeal deadline. The error is not the fault of the provider. An error occurred in the claims processing system that is identified after the 120-day appeal deadline has passed.

Texas Medicaid & Healthcare Partnership
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