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3.6.3 Claims Filing Involving a Medicaid Spend Down
Clients are responsible for informing their medical providers of their Medicaid eligibility and making arrangements to pay the charges used to meet the spend down amount. For CSHCN Services Program clients, the CSHCN Services Program may consider paying the charges used to meet the spend down for covered services.
TMHP-MNC notifies the client of:
• Bills or charges that were used to meet the spend down.
•Bills or charges that the client is financially responsible to pay.
•Bills or charges that the provider should submit to Texas Medicaid for consideration of payment.
Bills or charges not applied toward spend down or not previously submitted to the CSHCN Services Program, must be received by TMHP for Medicaid consideration within. These claims must be received 95 days from the date the client's eligibility was added to the TMHP file (add date). These bills must be on the appropriate claim form (such as CMS-1500 and UB-04 CMS-1450).
The client's payment responsibilities are as follows:
•When the entire bill was used to meet spend down, the client is responsible for payment of the entire bill. For CSHCN Services Program clients, submit the bill to the CSHCN Services Program for payment consideration.
•When a portion of a bill was used to meet the spend down, the client is responsible for paying the portion applied toward the spend down. For CSHCN Services Program clients, submit the bill to the CSHCN Services Program for payment consideration.
Claims are subject to the following:
•The claim must show the total billed amount for the services provided. Charges for ineligible days or spend down amounts must not be deducted or noncovered on the claim.
•A client's payment toward spend down must not be reflected on the claim submitted to TMHP.
Note: Payments made by the client for services that were not used in the spend down, but were incurred during an eligible period must be reimbursed to the client before the provider files a claim with TMHP.
Once eligibility is established, the client is eligible to receive the same care and services available to all other Medicaid clients.
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