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1.1.3.1 Provider Identifiers Terminated After 24 Months of No Claim Activity
Payment denial codes are applied to a Texas Provider Identifier (TPI) that has had no claim activity for a period of 24 months or more. The TPI will be considered inactive and will not be able to be used to submit claims.
A courtesy letter will be sent to all providers whose TPIs have been identified as not having any claims activity over the previous 18 months. Providers will have six months to submit claims and prevent the TPI from being terminated. If the provider is enrolled in both Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program, the provider identifiers for both programs will be examined to determine whether claims activity has occurred.
After 24 months without claim activity, providers will be sent a termination letter, and a payment denial code will be applied to their provider identifier. If a provider's Medicaid TPI is terminated, any enrollments with Primary Care Case Management (PCCM) or the CSHCN Services Program will also be terminated. Claims that are submitted for a terminated TPI after the payment denial code has been applied will be denied.
To have the payment denial code removed from a provider identifier, providers must submit a completed application for the state health-care program in which they wish to enroll, and the application must be approved. The information on this application must match exactly the information currently on the provider's file for the payment denial code to be removed.
For providers who are enrolled in any of the Texas Medicaid managed care organizations (MCOs), claim activity through the MCO will also be monitored to determine whether there is a lack of claim activity that warrants termination of the provider's agreement with Texas Medicaid.
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