HHSC Medical & Utilization Review (UR) Appeals

The Texas Health and Human Services Commission (HHSC) oversees the states Medicaid program, known as Texans&Families. When a provider or enrollee believes a medical service has been denied incorrectly, the HHSCs Utilization Review (UR) Appeals process provides a structured way to challenge that decision.

Why Appeals Matter

Medical decisions impact health outcomes and financial stability. An appeal can:

• Restore coverage for a needed service.
• Correct administrative errors.
• Ensure compliance with federal Medicaid rules.
• Provide documentation that can be used for future disputes.

Key Terms

• UR (Utilization Review): The process HHSC uses to determine whether a service is medically necessary and covered.
• Initial Determination: The first decision made after a claim is reviewed.
• Level1 Appeal: An informal review performed by the same reviewer or a different reviewer within HHSC.
• Level2 Appeal: A formal, written appeal reviewed by HHSCs Medical Director or a designated medical reviewer.
• Level3 Appeal: Review by an external Independent Review Entity (IRE) when the previous levels are exhausted.
• FERPA: Family Educational Rights and Privacy Act, relevant when educational records intersect with health records.

StepbyStep Appeal Process

1. Receive the Determination Letter

The determination letter explains why the service was denied, the applicable policy, and the time frame for appealing. Keep this letter; it is the foundation of your appeal.

2. Gather Supporting Documentation

Collect any records that demonstrate medical necessity, such as:

• Physician notes and progress reports.
• Diagnostic test results.
• Treatment plans and medication lists.
• Letters from specialists supporting the service.

Make sure each document is dated, signed, and clearly linked to the denied service.

3. File a Level1 Appeal (Informal Review)

Submit within 30 calendar days of the determination. The appeal can be sent by fax, mail, or through HHSCs online portal.

What to include:

• Patients name, Medicaid ID, and DOB.
• Reference to the original determination (date, case number).
• A concise statement of why the decision is incorrect.
• All supporting documentation.

If the denial involved a service that is noncovered by Medicaid, the level1 appeal may not be available; you would proceed directly to Level2.

4. Review the Level1 Decision

HHSC must respond within 15 calendar days. The response will either:

• Reverse the denial and approve the service.
• Uphold the denial, providing a clear explanation and establishing the next steps (typically Level2).

5. File a Level2 Appeal (Formal Written Appeal)

Submit within 30 calendar days after receiving the Level1 decision. The written appeal must be addressed to:

HHSC Utilization Review Appeals, 1019 N. 19th St., Austin, TX78701

Include:

• A cover letter restating the request and summarizing key points.
• The original determination letter.
• All documentation previously submitted, plus any new evidence.
• A signed statement from the provider attesting to medical necessity.

6. Level2 Review Outcome

The Medical Director (or a designated reviewer) must issue a decision within 30 calendar days. The decision will be final, unless the appellant elects to proceed to Level3.

7. Level3 Appeal Independent Review Entity (IRE)

If the Level2 decision remains unfavorable, an appeal can be filed with an IRE within 30 calendar days. The IRE operates independently of HHSC and follows federal Medicaid guidelines. The IREs decision is binding on HHSC.

Special Considerations

• Emergency Services: If a denied service is an emergency, providers may render care and seek retroactive approval under the Emergency Exception. Documentation of the emergency status is crucial.
• Prior Authorization Requirements: Some services require prior authorization. Failure to obtain it can lead to denial that is not appealable unless the provider can demonstrate a compelling reason for the omission.
• Timeliness: Missing appeal deadlines usually results in loss of the right to appeal. Document receipt dates and use certified mail or fax confirmation receipts.
• Language Access: HHSC must provide interpreter services for nonEnglish speakers. Requests for translation should be made early in the process.

Resources & References

• Texas Health and Human Services Commission (HHSC) website
• HHSC Appeals Process Overview
• Medicaid Medically Necessary Treatment (Federal)
• CMS Guidance on Independent Review Entities (2021)

Conclusion

The HHSC UR Appeals process is a multistep pathway designed to protect patients rights to necessary medical care while ensuring Medicaid resources are used appropriately. Understanding each level, respecting deadlines, and submitting clear, welldocumented appeals greatly increase the likelihood of a favorable outcome.

Providers and beneficiaries who are proactive, organized, and familiar with the required forms and timelines can navigate the system more effectively, ultimately securing the care that patients need.