Beginning October 1, 1990, hospitals may appeal adverse decisions made
under the TMRP and TEFRA review programs under the following guidelines.
(1) If a hospital receives notification from the Texas Department
of Health (department) or its contractor of an adverse decision regarding:
medical necessity of admission and/or continued stay, or diagnosis related
group (DRG) validation, the methods for appealing the decisions are as follows.
(A) If a hospital is dissatisfied with the original utilization
review decision made by the department or the department's contractor, the
hospital may submit a written request for a desk review to the Texas Department
of Health, Bureau of Medical Appeals, 1100 West 49th Street, Austin, Texas
78756-3172. The request should indicate the reason the decision by the department
was incorrect and must include a copy of the complete medical record; the
original signed, properly completed, and notarized affidavit in the format
provided or approved by the department, which allows the hospital to certify
the record as a business record. If the written request for a desk review
is not received by the department within 180 days from the date the hospital
received the original utilization review decision, the desk review shall not
be conducted. No appeal of any type is thereafter available on the merits
and the previous decision by the department shall be final. Any claim the
facility may have to the Medicaid funds at issue shall be barred. Extensions
of time shall not be granted for the filing of a written request for a desk
review, submission of the complete medical record, the notarized business
record affidavit.
(B) A desk review must be conducted by a department Bureau
of Medical Appeals physician. On completion of the review, a department Bureau
of Medical Appeals physician must render an appeal decision and notify the
hospital in writing of that decision. If any of the requirements of subparagraph
(A) of this paragraph are not met, the request for the desk review will be
dismissed for want of jurisdiction and the Bureau of Medical Appeals shall
consider the original decision made by the department as final.
(C) If a hospital is dissatisfied with the desk review decision
or if the hospital determines that the department has not followed its policy
concerning due process in its appeal rules, the hospital may request a contract
appeal hearing. The contract appeal hearing request must be submitted in writing
to the Texas Department of Health, Bureau of Medical Appeals, Hearing Request,
1100 West 49th Street, Austin, Texas 78756-3172, and must be received by the
department no later than 15 days from the date of receipt of the desk review
decision. Receipt of the written request for a contract appeal hearing within
15 days by the department's Bureau of Medical Appeals is a jurisdictional
prerequisite. Any such request received beyond the 15 days is subject to dismissal
for want of jurisdiction and the entry of an order sustaining the previous
decision by the Bureau of Medical Appeals.
(2) The hospital may appeal a technical denial to
the department if the hospital determines that the department or the contractor
issuing the denial made an incorrect denial or did not provide proper notification
of the technical denial.
(A) The hospital must submit a written request for a desk review,
accompanied by the complete medical record; an original signed, properly completed
and notarized business record affidavit in the format provided by or approved
by the department, which allows the hospital to certify the record as a business
record; and should state the reason the decision by the department or its
contractor was incorrect. The hospital must submit copies of any supporting
documentation at the time of filing the appeal. Appeals of final technical
denials must be received no later than 180 days from the date the hospital
receives the final technical denial notice from the department or its contractor
and must be sent to the Texas Department of Health, Bureau of Medical Appeals,
1100 West 49th Street, Austin, Texas 78756-3172. Receipt by the Bureau of
Medical Appeals of the written appeal request within the 180 days is a jurisdictional
prerequisite. Any such requests received beyond the 180 days is subject to
dismissal for want of jurisdiction and the entry of an order sustaining the
previous decision by the department or its contractor.
(B) If the requirements of subparagraph (A) of this paragraph
are met, the Bureau of Medical Appeals shall render a decision on the department's
or the contractor's final technical denial decision. If the department's
Bureau of Medical Appeals determines that the technical denial was issued
correctly, the Bureau of Medical Appeals shall consider the decision of the
department or the contractor as final and shall notify the hospital. If the
department's Bureau of Medical Appeals determines that the department's or
the contractor's decision was incorrect, the cases will be reviewed by the
department or the department contractor for a determination of the medical
necessity of the admission and/or continued stay, DRG validation, and quality
of care review. The department's Bureau of Medical Appeals will notify the
hospital of the final decision regarding the technical denial and of the decisions
made regarding the medical necessity of the admission and/or continued stay,
DRG validation, and quality of care review.
(C) If a hospital is dissatisfied with the decision in the
desk review, the hospital may request a contract appeal hearing. The contract
appeal hearing request must be submitted in writing by the Texas Department
of Health, Bureau of Medical Appeals, Hearing Request, 1100 West 49th Street,
Austin, Texas 78756-3172, and must be received by the department no later
than 15 days from the hospital's date of receipt of the desk review decision.
Receipt of the written request for a contract appeal hearing within the 15
days by the department's Bureau of Medical Appeals is a jurisdictional prerequisite.
Any such request received beyond the 15 days is subject to dismissal for want
of jurisdiction and the entry of an order sustaining the previous decision
by the Bureau of Medical Appeals.
(D) If a final technical denial is overturned by a hearing
examiner as a result of a contract appeal hearing, the case shall be referred
to the department's Bureau of Medical Appeals for a determination of the medical
necessity of the admission and or continued stay, DRG validation, and quality
of care review. The hospital is notified by the Bureau of Medical Appeals
if there is an adverse decision.
(E) If the hospital is dissatisfied with the decision made
by the department, the hospital is allowed to request a contract appeal hearing.
The request must be submitted in writing to and must be received by the Texas
Department of Health, Bureau of Medical Appeals, Hearing Request, 1100 West
49th Street, Austin, Texas 78756, no later than 15 days from the hospital's
date of receipt of the adverse decision. Receipt of the written request for
a contract appeal hearing within the 15 days by the Bureau of Medical Appeals
is jurisdictional prerequisite. Any such request received beyond the 15 days
is subject to dismissal for want of jurisdiction and the entry of an order
sustaining the previous decision by the Bureau of Medical Appeals or its contractor.
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| Source Note: The provisions of this §371.208 adopted to be effective February 1, 1991, 16 TexReg 232; amended to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective November 22, 1995, 20 TexReg 9274; amended to be effective March 25, 1996, 21 TexReg 2079; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308 |
