Provider Alert! Guidance on Appeals and Fair Hearing Requests due to COVID-19

Date: October 3, 2022

Attention: All providers

Effective Date: September 26, 2022

The content in this message will remain in effect through October 31, 2022 as announced by the Health and Human Services Commission (HHSC).

TCHP COVID-19 Utilization Management Procedure and provider alerts can be found here: http://www.thecheckup.org/provider-alerts/

Providers should monitor the Texas Children’s Health Plan Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: In response to COVID-19, Texas Children’s Health Plan (TCHP) supports the Health and Human Services Commissions’ (HHSC) guidance on the following temporary Medicaid and CHIP flexibilities related to utilization management during the public health emergency.

Members, legally authorized representatives or authorized representatives may request an appeal verbally without the member having to provide a written request and have extended timeframes as follows:

Appeals

• Ninety-(90) days to request an internal appeal with TCHP (Normally sixty-(60) days)

Fair Hearings

• One hundred and fifty-(150) days to request a fair hearing after notice of adverse action on an internal TCHP appeal. (Normally one hundred and twenty-(120) days)

Timeframe Flexibilities That Have Ended:

• Thirty (30) day deadline flexibility for Member request for continuation of benefits during appeal ended 6/30/2021.
  • Effective 7/1/2021, normal, regular and established timeframes resumed.
  • Members have 10 days after notice of adverse benefit determination to request continuation of benefits during appeal.

How this impacts providers: For informational purposes, should a member inquire about the appeal and fair hearing process during this time frame, TCHP members will receive communication on these changes as well.

Next steps for providers: No action required.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers