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5.11.1.2 HMO Copayments
The following text contains important information about HMO copayments:
• Claims submissions for HMO copayments must be received by TMHP within 95 days of the DOS. The other insurance EOB is not required for reimbursement of copays.
•TMHP pays the copayment in addition to the service the HMO or PPO has denied, if the client is eligible for Texas Medicaid and the procedure is reimbursed under Medicaid guidelines. Providers are not allowed to hold the client liable for the copayment.
•An office or emergency room (ER) visit (the ER physician is paid only when the ER is not staffed by the hospital) is reimbursed a maximum copayment of $10 per visit. The hospital ER visit is reimbursed at a maximum of $50 to the facility. TMHP pays up to four copayments per day, per client. ER visits are limited to one per day, per client, and are considered one of the four copayments allowed per day.
Important: By accepting assignment on a claim for which the client has Medicaid coverage, providers agree to accept payment made by insurance carriers and Texas Medicaid when appropriate as payment in full. The client cannot be held liable for any balance related to Medicaid-covered services.
The following Medicaid codes have been created for copayments, which are considered an atypical service:
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