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(a)Administrative Claim and Medical Appeals (1)An administrative claim appeal is a request for a review as defined in 1 TAC §354.2201(2). (2)A medical appeal is a request for review as defined in 1TAC §354.2201(9). (3)An administrative or medical appeal must be: (A)submitted in writing to HHSC Medicaid/CHIP Administrative Claim and Medical Appeals area by the provider delivering the service or claiming reimbursement for the service, and (B)submitted to HHSC Medicaid/CHIP Administrative Claim and Medical Appeals area 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 95 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. (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 1 TAC §354.1003. (6)Additional information requested by the HHSC Medicaid/CHIP Administrative Claim and Medical Appeals area 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. A determination made by the HHSC Medicaid/CHIP Administrative Claim and Medical Appeals area 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 1 TAC §354.2201(11). (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 the HHSC Medicaid/CHIP Administrative Claim and Medical Appeals area within 95 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 the 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 the 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 within 60 days of a complete request for appeal at HHSC. A determination made by HHSC Medicaid/CHIP Administrative Claim and Medical Appeals is the final decision in a utilization review appeal.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on September 29, 2003
TRD-200306413 Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 9, 2003
For further information, please call: (512) 424-6576
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