![]() 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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