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3.6.2.2 Provider Assistance to Clients with Spend Down
Providers may assist clients by:
• Submitting bills to TMHP-MNC for the CSHCN Services Program client that are not payable by the program.
•Submitting bills to TMHP-MNC for services provided to any other member of the family.
•Providing clients and families with current itemized statements.
•Encouraging clients to submit all their medical bills incurred from all providers.
Submitted bills must be itemized, showing the provider's name, client's name, CSHCN Services Program client number, MNP client number, dates of service, services provided, charge for each service, total charges, amounts of payments, dates of payments, and total due.
Bills for past accounts must be current itemized statements (dated in the last 60 days) from the provider, verifying the outstanding status of the account and the current balance due. Accounts with payments made by an insurance carrier, including Medicare, must be accompanied by the carriers EOB or a Medicare Summary Notice (formerly known as a Medicare Explanation of Benefits) showing the specific services covered and amounts paid.
When additional information is requested by TMHP-MNC, the applicant has 30 days from the date of the letter to respond. The provider may assist by furnishing the additional information to the applicant or sending it directly to TMHP-MNC in a timely manner.
TMHP-MNC does not pay bills; it only applies them toward the spend down. The provider must file a Medicaid claim after eligibility is established to have Texas Medicaid consider the claim for reimbursement. During the spend down period, there is no Medicaid coverage, and bills must not be sent to Texas Medicaid. A claim inadvertently filed to Texas Medicaid is denied due to client ineligibility.
Providers may make inquiries regarding status, months of potential eligibility, Medicaid or case number, and general client information by contacting the TMHP Contact Center at 1-800-925-9126, which is available Monday through Friday from 7 a.m. to 7 p.m., Central Time.
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