Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter I - MEDICAID PROGRAM APPEALS PROCEDURES › Division 3 - APPEALS › Section 354.2217 - Provider Appeals and Reviews

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Administrative Claim and Medical Appeals
(1)
					 An administrative claim appeal is a request for a review as defined in §
												RSA
					 354.2201(2) of this
					 title.
(2) A medical appeal is a
					 request for review as defined in §
												RSA
					 354.2201(9) of this
					 title.
(3) An administrative or
					 medical appeal must be:
(A) submitted in
					 writing to HHSC Medicaid/CHIP Administrative Claim and Medical Appeals by the
					 provider delivering the service or claiming reimbursement for the service,
					 and
(B) submitted to HHSC
					 Medicaid/CHIP Administrative Claim and Medical Appeals after the appeals
					 process with the claims administrator or claims processing entity has been
					 exhausted, and the documentation to the state must contain evidence of previous
					 claims administrator or claims processing entity appeal dispositions,
					 and
(C) a complete request and
					 contain all of the information necessary for consideration and determination by
					 HHSC Medicaid/CHIP Administrative Claim and Medical Appeals, including a
					 written explanation of the request for appeal and supporting documentation for
					 the request, and
(D) received by
					 HHSC Medicaid/CHIP Administrative Claim and Medical Appeals within 120 days
					 from the date of disposition by the claims administrator or claims processing
					 entity as evidenced by the Remittance and Status report sent to
					 providers.
(4) HHSC
					 Medicaid/CHIP Administrative Claim and Medical Appeals will only review appeals
					 that are received within 18 months from the date-of-service. This requirement
					 will be waived for the exceptions listed in §354.1003(f)(2)(B) and (C) and
					 §
												RSA
					 354.1003(g) of this
					 title.
(5) Providers must adhere to
					 all filing and appeal deadlines for an appeal to be reviewed by HHSC
					 Medicaid/CHIP Administrative Claim and Medical Appeals or its designee. The
					 filing and appeal deadlines are described in 354.1003 of this title.
(6) Additional information requested by HHSC
					 Medicaid/CHIP Administrative Claim and Medical Appeals must be returned to HHSC
					 within 21 calendar days from the date of the letter from HHSC Medicaid/CHIP
					 Administrative Claim and Medical Appeals. If the information is not received
					 within 21 calendar days, the case will be closed.
(7) HHSC Medicaid/CHIP Administrative Claim
					 and Medical Appeals is responsible for all administrative claim and medical
					 appeals. An administrative claim or medical appeal will be reviewed and a
					 determination made by HHSC Medicaid/CHIP Administrative Claim and Medical
					 Appeals within 90 days of the date a complete request for appeal is received at
					 HHSC. A determination made by HHSC Medicaid/CHIP Administrative Claim and
					 Medical Appeals is the final decision for administrative claim and medical
					 appeals.