TMPPM 2010 > Volume 1, General Information > Section 4: Client Eligibility > General Medicaid Eligibility > Retroactive Eligibility

4.1.1 Retroactive Eligibility

Medicaid coverage may be assigned retroactively for a client. For claims for an individual who has been approved for Medicaid coverage but has not been assigned a Medicaid client number, the 95-day filing deadline does not begin until the date the notification of eligibility is received from HHSC and added to the Texas Medicaid & Healthcare Partnership (TMHP) eligibility file.

The date on which the client's eligibility is added to the TMHP eligibility file is the add date. To ensure the 95-day filing deadline is met, providers must verify eligibility and add date information by calling the Automated Inquiry System (AIS) or using the TMHP Electronic Data Interchange (EDI) electronic eligibility verification.

If a person is not eligible for medical services under Texas Medicaid on the date of service, reimbursement for all care and services provided must be resolved between the provider and the client receiving the services. Providers are not required to accept Medicaid for services provided during the retroactive eligibility period and may continue to bill the client for those services. This guideline does not apply to nursing facilities certified by the Department of Aging and Disability Services (DADS).

If it is the provider's practice not to accept Medicaid for services during the retroactive eligibility period, the provider must use the policy consistently for all clients who request retroactive eligibility. Providers must inform the client about the policy before rendering services. If providers accept Medicaid assignment for the services and want to submit a claim for Medicaid-covered services for clients who receive retroactive eligibility, providers must refund payments received from the client before billing Medicaid for the services.

Note: The Medicaid managed care programs do not generally have retroactive eligibility.

The provider should also check the Eligibility Date on the Medicaid Identification Form (Form H3087) to see whether the client has retroactive coverage for previous bills. Clients with retroactive coverage are only issued one Medicaid Identification (Form H3087) showing the retroactive period. Texas Medicaid considers all services between the Eligibility Date and the Good Through date for reimbursement. Providers can determine whether a client has retroactive coverage for previous bills by verifying eligibility on www.tmhp.com, transmitting an electronic eligibility request, or calling AIS or the TMHP Contact Center.

Examples of Medicaid identification forms are found at the end of this section. Actual Medicaid forms can be identified by a watermark.

Refer to: Subsection 4.1, "Medicaid Identification Form H3087" in this section.

Section 8: Managed Care (Vol. 1, General Information).