1 Tex. Admin. Code § 354.2217 - Provider Appeals and Reviews

(a) Administrative Claim and Medical Appeals

(1) An administrative claim appeal is a request for a review as defined in § 354.2201(2) of this title.

(2) A medical appeal is a request for review as defined in § 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 § 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.

(b) Utilization Review Appeals

(1) A utilization review appeal is a request for review as defined in § 354.2201(11) of this title.

(2) A utilization review appeal must be:

(A) submitted in writing by the provider delivering the service or claiming reimbursement for the service, and

(B) received by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals within 120 days from the date of the decision letter from HHSC Medicaid Fraud and Abuse Utilization Review.

(C) a complete request and contain all the information required by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals including a written explanation of the request for appeal, and any necessary medical information.

(3) Additional information requested by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals must be returned to HHSC Medicaid/CHIP Administrative Claim and Medical Appeals within 21 calendar days of the request. If the information is not received within 21 calendar days, the case will be closed.

(4) A utilization review appeal will be reviewed and a determination made by HHSC within 60 days of the date a complete appeal is received at HHSC. A determination made by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals is the final decision in a utilization review appeal.

Notes

1 Tex. Admin. Code § 354.2217

The provisions of this §354.2217 adopted to be effective December 25, 2003, 28 TexReg 11252