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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.6 Utilization Review Process : 3.6.3 Technical Denials (DRG Prospective Payment) : 3.6.3.2 Mail-In Reviews

3.6.3.2
If the complete medical record is not received by HHSC within the specified time frame, a preliminary technical denial is issued by certified mail or fax. The hospital has 60 calendar days from the date of receipt of the notice to submit the complete medical record. If the complete medical record is not received by HHSC within this specified time frame, a final technical denial is issued and payment is recouped.
Hospital inpatient claim payments that have been recouped because of a technical denial may not be resubmitted on an outpatient claim.
Note:
A notarized business record affidavit in the format approved by HHSC is required for paper and electronic copies of requested medical records. A provider who fails to provide this documentation must resubmit the requested records with the affidavit.
Refer to:
Subsection 1.6.3, “Retention of Records and Access to Records and Premises,” in Section 1, “Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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