TMPPM 2009 > Provider Information > Managed Care > STAR+PLUS Program

7.3.4 Claims Filing Information

The claims filing guidelines found in "Prior Authorizations" , also apply to STAR+PLUS.

In addition to the claim types found on page 7-13, TMHP processes claims for the following STAR+PLUS clients/programs:

•All crossovers for deductibles and coinsurance on STAR+PLUS MQMBs

•All claims for Medicaid-only services (e.g., refractions, hearing exams, etc.) provided to STAR+PLUS MQMBs

TMHP will process and consider for payment inpatient hospital accommodations and related inpatient services (anything billed on an inpatient UB-04 CMS-1450 claim form). These services must be prior authorized by the client's HMO. After the provider requests prior authorization from the HMO, the HMO will forward the authorization to TMHP, and claims will be processed and considered for payment against the services authorized by the HMO. Claims received by TMHP without a prior authorization from the HMO will be denied.

For STAR+PLUS clients, the HMO will be responsible for processing and paying professional services. All authorizations, if required, for these claims must be submitted to the HMO and all claims for professional services must be submitted to the HMO.

STAR+PLUS MQMBs receive services and have their acute care claims processed as though they are not in a Medicaid managed care program. TMHP is responsible for reimbursing all Medicare coinsurance and deductibles that meet Medicaid payment criteria, as well as for all services that are a benefit of the Medicaid program (refractions, hearing exams, etc.) that are not covered under the Medicare program.

PCS services will not be processed or authorized for STAR+PLUS managed care organization (MCO) clients. The STAR+PLUS MCOs will continue to deliver PCS to their clients.