Provider Alert! End of Reconsideration Process for Denied services

Date: July 1, 2022

Attention: All Providers  

Effective date: August 1, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with 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.

TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons.

Call to action: The purpose of this communication is to inform providers that Texas Children’s Health Plan (TCHP) has updated our procedure following notification of our intent to deny a requested service.

Previously, TCHP accepted additional information submitted by providers within seven (7) days after a denial for reconsideration of service denials.

Effective 08/01/2022, TCHP will no longer follow a reconsideration process. TCHP will not review additional information submitted at any time after service denial and will follow the state mandated appeal process starting on 08/01/2022.

How this impacts providers: Effective 08/01/2022, after a provider is notified of our intent to deny a requested service:

• The provider receives a peer to peer notification letter for a denial or partial denial explaining that there is an intent to deny and a reason for denial.
• One business day after the peer to peer letter is sent, a denial letter is sent to the provider. This occurs even if a peer to peer call has already been scheduled.
• The provider has 60 business days from the date of the denial letter to request an appeal.
• Once an appeal has been requested, TCHP will review the appeal and issue a decision within 30 days for a standard appeal request and within 72 hours for an urgent appeal request.

This is a standard procedure that aligns with the HHSC requirement that authorization decisions are issued within a set time frame.

Next steps for Providers: Providers are strongly encouraged to share this communication with their staff and reach out to their Provider Relations Liaison for any questions or concerns.

Related Provider Communication:
Prior Authorization Requirements and Qualifications for Urgent Requests
http://www.thecheckup.org/2021/04/13/provider-alert-reminders-prior-authorization-requirements-and-qualifications-for-urgent-requests/

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.