5.2.8 Refunds to TMHP Resulting From Other Insurance
If the CSHCN Services Program makes payment for a claim and payment is received from another resource for the same services, the provider must refund the CSHCN Services Program the lesser of the amount paid by the TPR or the amount paid by the program. These refunds must not be held until the end of an accounting year. Providers must accept assignment; therefore, they must accept the CSHCN Services Program payment as payment in full for services that are a benefit and must not use payment by another TPR to make up the difference between the amount billed and the CSHCN Services Program payment.
Providers must use the following guidelines to determine the amount to be refunded to the CSHCN Services Program:
•When the CSHCN Services Program pays more than the other resource pays, the amount of the other payment is due as a refund to the CSHCN Services Program. For example:
Total billed
$300
CSHCN Services Program payment
$200
Other resource payment
$150
Amount to be refunded to TMHP
$150
•When the CSHCN Services Program pays less than the other resource, the amount paid by the Program is due as a refund. For example:
Total billed
$300
CSHCN Services Program payment
$200
Other resource payment
$250
Amount to be refunded to TMHP
$200
Texas Medicaid & Healthcare Partnership CPT only copyright 2008 American Medical Association. All rights reserved.
When the CSHCN Services Program pays more than the other resource pays, the amount of the other payment is due as a refund to the CSHCN Services Program. For example: