Provider Appeal Process to HHSC

Provider may appeal claim recoupment by submitting the following information to HHSC:

A letter indicating that the appeal is related to a managed care disenrollment/recoupment and that the provider is requesting an Exception Request.
The Explanation of Benefits (EOB) showing the original payment. Note: This is also used when issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an authorization for the exact items that were approved by the plan.
The EOB showing the recoupment and/or the plan’s “demand” letter for recoupment. If sending the demand letter, it must identify the client name, identification number, DOS, and recoupment amount. The information should match the payment EOB.
Completed clean claim. All paper claims must include the valid NPI number and TPI number.

Note: In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted with the authorization number and the provider will need to submit a corrected claim that contains the valid authorization number.

Mail appeal requests to:

     Texas Health and Human Services Commission
     HHSC Claims Administrator Contract Management
      Mail Code-91X
      P.O. Box 204077
      Austin, Texas 78720-4077