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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.5 Claims Filing and Reimbursement : 4.5.5 Claim Appeals

4.5.5
A claim denied because of age restrictions or other limitations listed in the Medicaid dental fee schedule may be considered for reimbursement on appeal when client medical necessity is provided to the TMHP Dental Director.
All denied claim appeals (see Section 7: Appeals [Vol. 1, General Information]) must be submitted to TMHP with the exception of a request to waive late filing deadlines. TMHP does not have the authority to waive state or federal mandates regarding claim filing deadlines.
If, after all appeal processes at TMHP have been exhausted, the provider remains dissatisfied with TMHP’s decision concerning the appeal, the provider may file a complaint with the HHSC Claims Administrator Operations Management Unit.
Refer to:
Subsection 7.3.1, “Administrative Claim Appeals” in Section 7, “Appeals” (Vol. 1, General Information).
Note:
Refer to:
Subsection 7.1.4, “Paper Appeals” in Section 7, “Appeals” (Vol. 1, General Information).
Providers may use one of three methods to appeal Medicaid claims to TMHP: telephone (AIS), paper, or electronic.
All appeals of denied claims or requests for adjustments on paid claims must be received by TMHP within 120 days of the date of disposition of the R&S Report on which the claim appears. If the 120-day appeal deadline falls on a weekend or TMHP-recognized holiday, the deadline will be extended to the next business day.
Certain claims must be appealed on paper; they cannot be appealed either electronically or by telephone.
Refer to:
Subsection 7.1.4, “Paper Appeals” in Section 7, “Appeals” (Vol. 1, General Information) for information about appeals that may not be appealed electronically and claims that may not be appealed through AIS.
To appeal in writing:
If a claim cannot be appealed electronically or by telephone, appeal the claim on paper by completing the following steps:
1)
2)
3)
Identify the information that was incorrectly provided and note the correct information that should be used to appeal the claim. If necessary, specify the reason for appealing the claim.
4)
5)
6)
7)
It is strongly recommended that providers submitting paper appeals retain a copy of the documentation being sent. It is also recommended that paper documentation be sent by certified mail with a return receipt requested to establish TMHP’s receipt of the claim and the date the claim was received. The provider is urged to retain copies of multiple claim submissions if the Medicaid provider identifier is pending.
Note:
Claims submitted by newly-enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the DOS.
8)
Texas Medicaid & Healthcare Partnership
Inquiry Control Unit
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
To appeal by telephone:
1)
2)
3)
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The appeal will appear as finalized or pending on the following week’s R&S Report.
Providers may also appeal electronically.
Electronic appeal submission is a method of submitting Texas Medicaid appeals using a personal computer. The electronic appeals feature can be accessed directly through the TMHP EDl Gateway or by using TexMedConnect. For additional information, contact the TMHP EDI Help Desk at 1‑888‑863‑3638.
Electronic appeals can increase accuracy of claims processing, resulting in a more efficient case flow to the provider:

Texas Medicaid & Healthcare Partnership
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