8.2.6 Claims Filing InformationClaims for Medicaid managed care clients enrolled in a STAR HMO must be submitted to the STAR health plan in which the client is enrolled at the time of service (or date of admission for inpatient hospital claims). The STAR HMO, as a secondary payor, does not determine payment based on the primary payor's authorization of services or approval of hospital stays. Personal care services for STAR will be authorized and may be reimbursed by TMHP. Exception: TMHP processes some claims for HMO clients. See subsection 8.1.13, "TMHP Claims Filing Information" in this section for details. A provider must file a claim with the MCO or its Subcontracted Claims Processor within 95 days from the DOS. If a claim is not received by the MCO within 95 days, the claim will be denied. If the provider files with the wrong plan within the 95 day submission requirement (e.g., State Claims Administrator but not with the MCO) and produces documentation to that effect, the MCO must honor the initial filing date and process the claim without denying the resubmission for the sole reason of passing the filing timeframe. The provider must file the claim with the correct MCO within 95 days of the date on the Remittance and Status (R&S) Report from the other (wrong) carrier. When a service is billed to a third party insurance resource other than the MCO, the claim must be refiled and received by the MCO within 95 days from the date of disposition by the other insurance resource. The MCO will determine, as a part of its provider claims filing requirements, the documentation required when a provider refiles these types of claims with the MCO. MCOs are subject to the requirements related to coordination of benefits for secondary payers in the Texas Insurance Code section 843.349 (e) and (f). |
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Texas Medicaid & Healthcare Partnership CPT only copyright 2009 American Medical Association. All rights reserved. |
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