CSHCN 2009 > Provider Enrollment and Responsibilities > Provider Responsibilities

2.3.8 Billing Clients

CSHCN Services Program clients, parents, or guardians of children eligible for CSHCN Services Program benefits must not be billed for CSHCN Services Program covered services. CSHCN Services Program providers must agree to accept the CSHCN Services Program allowed amount of payment (regardless of payer) as payment in full for covered services provide to CSHCN Services Program clients. Providers may collect allowable insurance or health maintenance organization co-payment, in accordance with those plan provisions.

CSHCN Services Program providers must agree to accept the CSHCN Services Program allowed amount of payment (regardless of payer) as payment in full for covered services provided to CSHCN Services Program clients. A provider must not require a down payment, bill, or take recourse against an eligible client for a denied or reduced claim for services that are within the amount, duration, and scope of benefits of the CSHCN Services Program when the action is the result of any of the following provider errors:

•Failure to submit a claim, including claims not received by TMHP.

•Failure to submit a complete authorization or prior authorization request, on a program-approved form, within the established deadlines.

•Failure to submit a claim within the 95-day filing deadline.

•Filing an incorrect claim.

•Failure to resubmit a corrected claim or to appeal a claim within the 120-day correction and resubmission period.

•Errors made in claims preparation, claims submission, or in the correction and resubmission (appeal) process.

•Failure to submit a request for Administrative Review to the DSHS-CSHCN Services Program within 30 days of the date of the resubmission (appeal) denial.

A provider attempting to bill or recover money from a client is in violation of the above conditions and may be subject to exclusion from the CSHCN Services Program.

A provider may bill the client for:

•Any service that is not a benefit of the CSHCN Services Program, such as obstetrical care.

•All services incurred on noncovered days due to eligibility or inpatient hospital or inpatient rehabilitation day-limitations. Total client liability must be determined by reviewing the itemized statement and identifying specific charges incurred on the noncovered day.

Each provider must furnish services to eligible CSHCN Services Program clients in the same manner, to the same extent, and of the same quality as services provided to other clients. Services made available to other clients must be made available to CSHCN Services Program clients when the services are benefits of the CSHCN Services Program.

Clients must not be billed for the completion of a claim form, even when it is a provider's office policy to do so.

Refer to: Chapter 4, "Authorizations and Prior Authorizations".

Chapter 5, "Claims Filing, Third-Party Resources, and Reimbursement".

Chapter 7, "Appeals and Administrative Review".