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5.2.4 Verbal Denials by a TPR
When a claim is denied by TMHP because of the client's other coverage, information identifying the TPR appears on the provider's R&S Report. The claim must not be refiled with TMHP until a disposition from the TPR is received or until 110 days have elapsed since the billing of the claim to the TPR with no disposition received.
A statement from the client or family member indicating that they no longer have this resource is not sufficient documentation to reprocess the claim. Providers may call the third-party insurance resource and receive a verbal denial. In these situations, the provider must indicate the following information on the R&S Report:
• Date of the telephone call
•Name and telephone number of the insurance company
•Name of the person with whom they spoke
•Policyholder and group information
•Specific reason for the denial (include client's type of coverage to enhance the accuracy of claims processing; for example, a policy that covers only inpatient services or only physician services)
If a TPR has not responded or delays payment/denial of a provider's claim for more than 110 days after the date the claim was billed, the CSHCN Services Program considers the claim for payment. The following information is required:
•The name and address of the TPR.
•The date the TPR was billed (used to calculate the filing deadline).
•A statement signed and dated by the provider that no disposition was received from the TPR within 110 days from the date the claim was filed.
When a provider is advised by a TPR that benefits were paid to the client, the provider must include that information on the claim with the date and amount of payment made to the client, if available. If a denial was sent to the client, refer to the information listed in this section. This information enables TMHP to consider the claim for payment.
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