12/21/2023 0 Comments Timely filing appeal letterClaims that are the result of a mass adjustment.Įxception:Inpatient hospital claims denied for lack of a Hysterectomy Acknowledgment Statement or a Sterilization Consent Form may be appealed electronically if the requested form has been faxed according to the instructions in the Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information on the TMHP website at 7.1.2 Resubmission of TMHP Electronic Data Interchange (EDI) Rejections.Claims with quantity billed changes in the claims details.Claims denied as past the payment deadline.Claims denied as past filing deadline except when retroactive eligibility deadlines apply.Claims listed as pending or in process with explanation of pending status (EOPS) messages.Diagnosis-related group (DRG) assignment.Claims that require supporting documentation (e.g., operative report, medical records, home health, hearing aid, and dental X-rays).The following claims may not be appealed electronically: Appeal submission windows can be automatically filled in with electronic R&S (ER&S) Report information, thereby reducing data entry time.Maintained audit trails through print and download capabilities.Increased accuracy of appeals filed to potentially improve cash flow.Using electronic appeal submission provides the following advantages to the users: The Health Insurance Portability and Accountability Act (HIPAA) standard American National Standards Institute (ANSI) ASC X12 837 format is accepted by TMHP EDI.įor other information, contact the TMHP EDI Help Desk at 88.ħ.1.1.1 Advantages of Electronic Appeal Submission The electronic appeals feature can be accessed by a business organization (e.g., billing agents) interfacing directly with the TMHP Electronic Data Interchange (EDI) Gateway or through TexMedConnect, the free web-based application available from TMHP. 2, Provider Handbooks) for additional information about managed care appeals.Įlectronic appeal submission is a method of submitting appeals using a personal computer. The Medicaid Managed Care Handbook ( Vol. Refer to: Subsection 7.3.3, “Utilization Review Appeals” in this section. The only managed care appeals administered by TMHP are those for carve-out services. Note:Appeals for managed care claims must be submitted to the managed care organization (MCO) or dental plan that administers the client’s managed care benefits. These must be submitted to HHSC Medical and UR Appeals. TMHP is not responsible for managing appeals resulting from utilization review (UR) decisions by the HHSC Office of Inspector General (OIG) UR Unit. HHSC Claims Administrator Operations Management Texas Health and Human Services Commission HHSC is the sole adjudicator of this final appeal.Īll providers must submit second-level administrative appeals and exceptions to the 95-day filing deadline appeals to the following address: This appeal is submitted by the provider to HHSC, which may subsequently require TMHP to gather information related to the original claim and the first-level appeal. It has been denied again for the same reason(s) by TMHP.It has been appealed as a first-level appeal to TMHP.It has been denied or adjusted by TMHP.This appeal is submitted by the provider directly to TMHP for adjudication and must contain all required information to be considered.Ģ) A second-level appeal is a provider’s final medical or standard administrative appeal to HHSC of a claim that meets all of the following requirements: After the provider has exhausted all aspects of the appeals process for the entire claim, the provider may submit a second-level appeal to HHSC.ġ) A first-level appeal is a provider’s initial standard administrative or medical appeal of a claim that has been denied or adjusted by TMHP. Standard administrative requests and medical appeals must be sent first to TMHP or the claims processing entity as a first-level appeal. If the 120-day appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day. TMHP must receive all appeals of denied claims and requests for adjustments on paid claims within 120 days from the date of disposition of the Remittance and Status (R&S) Report on which that claim appears. Providers may use three methods to appeal Medicaid fee-for-service and carve-out service claims to Texas Medicaid & Healthcare Partnership (TMHP): electronic, Automated Inquiry System (AIS), or paper. An appeal is a request for reconsideration of a previously dispositioned claim.
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