TMPPM 2008 >4.2 Medicaid Identification and Verification

4.2 Medicaid Identification and Verification

Providers are responsible for requesting and verifying current eligibility information from the client by asking the client to produce Medicaid Identification (Form H3087 or H1027) issued for the month in which services are provided. Providers must accept either of these documents as valid proof of eligibility. Providers should retain a copy for their records to ensure the person is eligible for Medicaid when the services are provided. Clients should share eligibility information with providers. providers should request additional identification if they are unsure whether the person presenting the form is the person identified on the form. providers should check the Eligibility Date to see whether the client has possible retroactive coverage for previous bills.

Providers must review limitations identified on the client's Medicaid Identification Form H3087 or their Medicaid Eligibility Verification Form H1027. Clients may be limited to one primary provider or pharmacy. Qualified Medicare Beneficiary (QMB) clients will be limited to Medicaid coverage of the Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance for Medicare services.

Only those clients listed on the Medicaid Identification form are eligible for Medicaid. If a person insists he or she is eligible for Medicaid but cannot produce a current Medicaid Identification Form H3087, providers can verify eligibility through AIS or TMHP EDI. Providers must document this verification in their records and treat these clients as if they had presented a Medicaid Identification (Form H3087) or Medicaid Eligibility Verification (Form H1027).

If clients have lost their identification or forgotten to bring it to appointments, providers may verify their eligibility as indicated in "Eligibility Verification" and treat the clients the same as though they had presented Medicaid Identification (Form H3087) or Medicaid Verification Letter (Form H1027). HHSC issues one of the following only when Form H3087 is lost or stolen or in the event of temporary emergency Medicaid:

•Form H1027-A. Medicaid eligibility verification is used to indicate eligibility for clients who receive regular Medicaid coverage.

•Form H1027-B. Medicaid Qualified Medicare Beneficiary (MQMB) is issued to clients eligible for MQMB coverage.

•Form H1027-C. QMB is issued to clients who are eligible for QMB coverage only.

Refer to: "QMB/MQMB Identification" .

The Medicaid Eligibility Verification Form H1027 (Medicaid Verification Letter) is acceptable as evidence of eligibility during the eligibility period of the letter unless the letter contains limitations that affect the eligibility for the intended service. Providers must accept either of these documents as valid proof of eligibility. If the client is not eligible for medical assistance or certain benefits, the client is treated as a private-pay patient.

Note: When treating a STAR Program member, providers must refer to the Medicaid Identification Form H3087 and, if applicable, the member's health plan ID card.

Medicaid clients in Cameron, Hidalgo, and Travis counties are now issued a Medicaid Access Card, which is a plastic smart card that automates client check-in and eligibility verification. In these counties, clients use their Medicaid Access Card in place of the Medicaid Identification (Form H3087) to identify themselves as eligible for Medicaid. If a Medicaid client with one of these cards sees a provider for service in an area that is not using the new process, providers can still verify the client's Medicaid eligibility either by using existing processes or by calling the TMHP Contact Center at 1-800-925-9126.

If the client is reported as eligible and no other limitations of eligibility affect the intended service, proceed with the service. Eligibility during a previous month does not guarantee eligibility for the current month. The Medicaid Eligibility Verification Form H1027, the Medicaid Identification Form H3087, and the PCCM Monthly Panel Report are the only documents that are honored as verification of Medicaid eligibility. The right side of the Medicaid Identification Form H3087 consists of information about limited services provided to clients. A check mark indicates eligibility for a particular service.

Important: Emergency THSteps dental services, or THSteps dental or medical checkups services may be provided when medically necessary.

•Reminders of medical and dental checkups appear under the client's name during the month the client is eligible for routine checkups.

•All Medicaid clients birth through 20 years of age are eligible to receive medically necessary dental services.

Providers should update the appropriate columns of the Medicaid Identification to indicate services received by the client. Providers put a slash (/) with an initial and date in the column to indicate the service was provided. Providers can check the third-party resource (TPR) column on the Medicaid Identification Form H3087 to determine whether the client has other health insurance.

Refer to: "Third-Party Resources (TPR)" for more information and "Medicaid Identification Form H3087" .

In accordance with current federal policy, Texas Medicaid and Texas Medicaid clients cannot be charged for the client's failure to keep an appointment. Only bills for services provided are considered for payment. Clients may not be billed for the completion of a claim form, even if it is a provider's office policy.