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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.3 Appeals to HHSC Texas Medicaid Fee-for-Service : 7.3.3 Utilization Review Appeals

Hospitals may appeal adverse UR decisions made by the HHSC OIG UR Unit to the HHSC Medical and UR Appeals Unit. The written appeal request, with complete medical record and approved Business Records Affidavit Form must be received by the Medical and UR Appeals Unit within 120 days of the date of the original HHSC OIG UR decision letter. If the appeal request with all required documentation is not received within 120 days, the appeal is not conducted, and the HHSC OIG UR decision is considered final. Any claim the facility may have to the Medicaid funds at issue are barred. Extensions of time are not granted for filing the written appeal request and submitting all of the required documentation. The procedures and specific requirements for appealing these decisions can be found in the sections that follow.
Hospitals may appeal adverse HHSC OIG UR Unit determinations to the following address:
HHSC Medical and UR Appeals
Mail Code H-230
PO Box 85200
Austin, TX 78708
4900 North Lamar (Express Mail Only)
Austin, TX 78751

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