TMPPM 2008 > Provider Information > Provider Enrollment and Responsibilities > Provider Responsibilities

1.2.8 Billing Clients

A provider cannot require a down payment before providing Medicaid-allowable services to eligible clients, bill, nor take recourse against eligible clients for denied or reduced claims for services that are within the amount, duration, and scope of benefits of the Texas Medicaid Program if the action is the result of any of the following provider-attributable errors:

•Failure to submit a claim, including claims not received by TMHP.

•Failure to submit a claim to TMHP for initial processing within the 95-day filing deadline (or the initial 365-day deadline if applicable).

•Submission of an unsigned or otherwise incomplete claim such as omission of the Hysterectomy Acknowledgment Statement or Sterilization Consent Form with claims for these procedures.

•Filing an incorrect claim.

•Failure to resubmit a corrected claim or rejected electronic media claim within the 120-day resubmittal period.

•Failure to appeal a claim within the 120-day appeal period. Errors made in claims preparation, claims submission, or appeal process.

•Failure to submit a claim to TMHP within 95 days of a denial by Titles V or XX for family planning services.

•Failure to submit a claim within 95 days from the disposition date from Medicare or a primary third party insurance resource.

•Failure to obtain prior authorization for services that require prior authorization under the Texas Medicaid Program.

Providers must certify that no charges beyond reimbursement paid under the Texas Medicaid Program for covered services have been, or will be, billed to an eligible client. Federal regulations prohibit providers from charging clients a fee for completing or filing Medicaid claim forms. Providers are not allowed to charge TMHP for filing claims. The cost of claims filing is part of the usual and customary rate for doing business.

Medicaid payment to physicians for covered services includes the incidental services such as completion of required forms submitted by a nursing facility to the physician for signature. It is not acceptable for the physician to charge Texas Medicaid Program clients, their family, or the nursing facility for telephone calls, telephone consultations, or signing forms. Medicaid payment is considered payment in full. The visit reimbursement includes the incident to required paperwork.

In accordance with current federal policy, the Texas Medicaid Program and Texas Medicaid Program clients cannot be charged for the client's failure to keep an appointment. Only billings for services provided are considered for payment. Clients may not be billed for the completion of a claim form, even if it is a provider's office policy.

Letters of inquiry about client billing are sometimes sent to providers in lieu of telephone calls from TMHP representatives. In either case, it is mandatory that the questions be answered with the requested pertinent information. Upon receipt, TMHP forwards these letters to HHSC. HHSC uses the information to resolve client billing/liability issues. It is mandatory that these letters be signed, dated, and returned within ten business days.

Refer to: "Outpatient" for more information about spell of illness.

"Medically Needy Program (MNP)" .

"Private Pay Agreement".