A written appeal request with all required documentation must be received by Medical and Utilization Review (UR) Appeals within 120 calendar days of the date of the decisions letter.
HHSC Medical and UR Appeals may ask for additional documentation. If requested, it must be received within 21 calendar days of the date of the request.
If you have questions about the appeals process, you can email the HHSC Medical and UR Appeals team. Learn more about the HHSC Medical and UR Appeals Email Box (PDF).
Texas Medicaid Policies
Texas Medicaid Provider Procedures Manual (TMPPM) Volume 1: Section 7: Appeals (PDF) (7.3.3 for Utilization Review Appeals)
TMPPM Volume 2: Inpatient and Outpatient Hospital Services Handbook (PDF)
Texas Administrative Code (TAC) Rules
1 TAC § 354.2201 – General/Definitions
1 TAC § 354.2217 – Provider Appeals and Reviews
1 TAC § 371.208 – Appeals Related to Utilization Review Department Review Decisions
Resources
- Appeal Overview (PDF)
- Appeal Submission Requirements and Related Policies (PDF)
- Documentation Requirements (PDF)
- Tips for Properly Preparing Medical Records (PDF)
- Affidavit Requirements (PDF)
- Tips for a RAC Appeal Letter (PDF)
- Tips for an Appeal Letter other than RAC (PDF)
- Additional Submission Requirements for Third Party Companies and Corporate Offices (PDF)
- HHSC Medical and UR Appeals Review Process (PDF)
- Adjustment Requests to Rebill Claims as Observation (HHSC OIG UR only) (PDF)
- Educational Case Conferences (PDF)
- Procedure for Requesting "Appeal Status Updates" (non-RAC Appeals) (PDF)