Member eligibility changed from one Managed Care Organization (MCO) to another on the date of service.
Providers may appeal claims payment recoupments and denials of services by submitting the following information to the appropriate MCO to which the Member eligibility was changed on the date of service:
- 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 Payment (EOP) showing the original payment. The EOP showing the recoupment and/or the MCO’s ‘‘demand’’ letter for recoupment must identify the client’s name, identification number, DOS, and recoupment amount. The information should match the payment EOP.
- Documentation must identify the client’s name, identification number, DOS, recoupment amount, and other claims information.
NOTE: Label the request ‘‘Expedited Review Request’’ at the top of the letter to ensure the appeal request is reviewed prior to 18 months from the date of service.
Submit appeals to Community First online via the Provider Portal.
Mail Fee-for-Service-related appeal requests to:
Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
P.O. Box 204077
Austin, TX 78720-4077
Action
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider E-Newsletter