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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.3 Appeals to HHSC Texas Medicaid Fee-for-Service : 7.3.2 Medical Necessity Appeals

7.3.2
Medical necessity appeals are defined as disputes regarding medical necessity of services. Providers must appeal to TMHP and exhaust the appeal/grievance process before submitting an appeal to HHSC.
Medical necessity appeals related to UR decisions made by the HHSC OIG UR Unit must be appealed to HHSC not TMHP.
When filing appeals to HHSC, providers must submit copies of all supporting documentation, including information sent to TMHP.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.