Clarification regarding EXL and Cotiviti Appeal Process & Medical Records Request Timelines

Date: August 14, 2026

Attention: All Providers

Texas Children's Health Plan (TCHP) adheres to Medicaid reimbursement guidelines and complies with payment integrity guidance as issued by the Texas Office of Inspector General (OIG). TCHP utilizes two vendors for payment integrity audits, Cotiviti and EXL. The provider audit appeal process is designed to ensure providers have an opportunity to submit additional supporting documentation and request reconsideration of audit findings. Effective September 1, 2026 TCHP is transitioning from a three-level appeal process to a two-level appeal process for EXL and Cotiviti payment integrity audits and tightening timelines for medical records requests.

Summary

Providers are given three opportunities to submit medical records requests for audits.

Providers are entitled to a two-level appeal process for EXL and Cotiviti payment integrity audits.

Medical Records Request Timelines

Initial medical records request: Providers have 30 calendar days to send in supporting documentation. If nothing is received by the requesting vendor a second medical records request will be sent to the provider.
Second medical records request: Providers have 15 calendar days to send in supporting documentation. If nothing is received by the requesting vendor a third and final medical records request will be sent to the provider.
Final medical records request: Providers have 10 calendar days to send in supporting documentation. If nothing is received by the requesting vendor then the audit findings will be finalized accordingly.

These timelines align with industry standards for claims audits and will allow for audits to be conducted in an efficient manner.

Appeals Process

Initial Findings Letter
Level 1 Appeal Review
Level 2 Appeal Review (Final Determination)

How the Process Works

Step 1: Findings Letter

Providers will receive a Findings Letter detailing the audit results.

Providers will have 30 calendar days from the date of the Findings Letter to submit a first-level appeal and any supporting documentation to the respective vendor.

Step 2: First-Level Appeal Review

The respective vendor, EXL or Cotiviti, will review the appeal submission and supporting documentation.

A written determination will be issued to the provider.

Step 3: Second-Level Appeal Review (Final Appeal)

If the provider disagrees with the first-level appeal determination, a second-level appeal may be submitted within 30 calendar days from the date of the determination letter to the respective vendor.

Following review of the second-level appeal, the respective vendor, EXL or Cotiviti, will issue a final determination. This decision will be considered final and will exhaust the provider's appeal rights related to the audit finding.

This dual level appeal process aligns with industry best practices while improving administrative efficiency and reducing delays in resolving audit findings.

What Providers Can Expect

Providers are encouraged to:

Review all audit correspondence promptly.
Submit complete supporting documentation within the required timeframe.
Monitor communications from EXL and/or Cotiviti.
Adhere to all appeal submission deadlines and instructions, as late submissions may not be considered.
NOTE: record submissions and appeals must be submitted directly to the respective vendor in accordance with the instructions in the letters. Do not submit records or appeals directly to TCHP.

Next Steps

Providers should share this information with their billing and administrative teams, ensure internal processes are in place to route audit appeals to EXL and Cotiviti, and actively monitor for audit notifications to respond promptly.

If you have any questions or require additional information, please reach out to your assigned Account Lead or Provider Relations Liaison (PRL). If you’re unsure who your Account Lead or PRL is, you can find contact details on our Meet Our Team page.

TCHP appreciates your cooperation and partnership in maintaining the integrity of services provided to our members.

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org.

For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts