TMPPM 2007 >4.2 Medicaid Identification, Verification

4.2 Medicaid Identification, Verification

Providers are responsible for requesting and verifying current eligibility information from the client by asking the client to produce Medicaid Identification (Form H3087 or H1027) issued for the month that services are provided. Providers must accept either of these documents as valid proof of eligibility. Providers should retain a copy for their records to ensure the person is eligible for Medicaid when the services are provided. The provider should request additional identification when unsure the person presenting the form is the person identified on the form. The provider should check the Eligibility Date to see if the client has possible retroactive coverage for previous bills.

Important: Providers must review limitations identified on the client's Form H3087 or Form H1027. Clients may be limited to one primary provider or pharmacy. QMB clients will be limited to Medicaid coverage of the Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance for Medicare services.

Only those clients listed on the Medicaid Identification form are eligible for Medicaid. If a person insists he or she is eligible for Medicaid but cannot produce a current Medicaid Identification form, providers can verify eligibility through AIS or TMHP EDI. Providers must document this verification in their records and treat the client as usual.

HHSC issues one of the following only when Form H3087 is lost or stolen or in the event of temporary emergency Medicaid:

•Form H1027-A. Medical Eligibility Verification is used to indicate eligibility for clients who receive regular Medicaid coverage.

•Form H1027-B. Medicaid Qualified Medicare Beneficiary (MQMB) is issued to clients eligible for MQMB coverage.

•Form H1027-C. Qualified Medicare Beneficiary (QMB) is issued to clients who are eligible for QMB coverage only.

Refer to: "QMB, MQMB" .

Form H1027 (Medicaid Verification Letter) is acceptable as evidence of eligibility during the eligibility period of the letter unless the letter contains limitations that affect the eligibility for the intended service. Providers must accept either of these documents as valid proof of eligibility. If the client is not eligible for medical assistance or certain benefits, the client is treated as a private-pay patient.

Note: When treating a STAR Program member, providers must refer to Form H3087 and, if applicable, the member's health plan ID card.

If the client is reported as eligible and no other limitations of eligibility affect the intended service, proceed with the service. Eligibility during a previous month does not guarantee eligibility for the current month. Forms H1027, H3087, and the PCCM Monthly Panel Report are the only documents that are honored as verification of Medicaid eligibility. The right side of Form H3087 consists of information about limited services provided to clients. A check mark on the line to the right of the client's name indicates eligibility for a particular service.

Important: Emergency THSteps dental services, or THSteps dental or medical check ups services may be provided when medically necessary.

•Reminders of medical and dental check ups appear under the client's name during the month the client is eligible for routine check ups.

•All Medicaid clients birth through 20 years of age are eligible to receive medically necessary dental services.

Providers should update the appropriate columns of the Medicaid Identification to indicate services received by the client. Providers put a slash (/) with an initial and date in the column to indicate the service was provided. Providers can check the third party resource (TPR) column on the Form H3087 to determine if the client has other health insurance.

Refer to: "Third Party Resources (TPR)" for more information and "Medicaid Identification Form H3087" .