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4.5.1 Spend Down Processing
Applicants are instructed to submit all their medical bills or completed claim forms for application toward their spend down to TMHP MNC along with Form H1120. Charges from the bills or completed claim forms are applied in date of service order to the spend down amount, which is met when the accumulated charges equal the spend down amount.
Providers can assist medically needy clients with their application by giving them current, itemized statements or completed claim forms to submit to MNC. MNC holds manually completed claim forms used to meet spend down for ten calendar days preceding the completion of the spend down case, then forwards them to claims processing. The prohibition against billing clients does not apply until Medicaid coverage is provided.
Current itemized statements or completed claim forms must include the following:
• Statement date.
•Provider name.
•Client name.
•Date of service.
•All services provided and charges.
•Current amount due.
•Any insurance or client payments with date of payment (the date and amount of any insurance or payments).
Important: Amounts used for spend down are deducted from the total billed amount by the provider. Using older bills may provide earlier eligibility for the client.
Unpaid bills incurred before the month of potential eligibility (the month with spend down) may be used to meet spend down. Itemized statements must be dated within 60 days of the date received at TMHP MNC.
Clients have 30 days to submit their bills or completed claim forms. Thirty-day extensions are available to the client as necessary to gather all needed information.
The unpaid balance on currently due accounts may be applied toward the spend down regardless of the date of service. All bills or completed claim forms must be itemized showing the provider's name, client's name, dates of service, statement date, services provided, charge for each service, total charges, amounts and dates of payments, and total due.
Bills for past accounts must be current, itemized statements (dated within the last 60 days) from the provider verifying the outstanding status of the account and the current balance due. Accounts that have had payments made by an insurance carrier including Medicare must be accompanied by the carrier's explanation of benefits (EOB) or Remittance Advice showing the specific services covered and amounts paid.
If the MNC requests additional information, the applicant has 30 days from the date of the clearinghouse letter to respond. This response may be the return of the information requested, a request for an extension of the response period, or a request to withdraw the bill from consideration. The provider can assist by furnishing the additional information to the applicant.
All communication about submission of billing information is carried out between MNC and the applicant; however, providers can assist clients by:
•Providing clients with current itemized statements or completed claim forms.
•Encouraging clients to submit all their medical bills or completed claim forms incurred from all providers at the same time.
•Submitting manual claim forms directly to MNC or to applicants for the MNP, to be used to meet spend down.
Bills or claim forms submitted to MNC are for application toward the spend down only. Submitting a bill or claim forms for spend down is not a claim for reimbursement. No claims reimbursement is made from such submittals unless the claim form is complete. The provider must file a Medicaid claim after eligibility has been established to have reimbursement considered by the Texas Medicaid Program. If the provider assisted the client with submission of a claim form, the MNC retains all claim forms for ten calendar days preceding the completion of the spend down case. The MNC then forwards all claim forms directly to claims processing to have reimbursement considered by the Texas Medicaid Program.
MNC informs the applicant and HHSC when the spend down is met. HHSC certifies the applicant for Medicaid and sends the Medicaid Identification form to the applicant when Medicaid eligibility is established. Clients are encouraged to inform medical providers of their Medicaid eligibility and make arrangements to pay the charges used to meet the spend down amount. When notified of Medicaid eligibility, the provider asks if the client has retroactive eligibility for previous periods. All bills submitted to MNC are returned to the client, except for claim forms. An automated letter specific to the client's spend down case is attached, indicating which:
•Bills/charges were used to meet the spend down.
•Bills/charges the client is responsible for paying in part or totally.
•Bills the provider may submit to Medicaid for reimbursement consideration.
•Claims are received and forwarded to TMHP claims processing.
Providers may inquire about status, months of potential eligibility, Medicaid or case number, and general case information by calling the TMHP Contact Center at 1-800-925-9126.
Medically needy applicants who have a case pending or have not met their spend down are considered private-pay clients and may receive bills and billing information from providers. No claims are filed to Medicaid. A claim that is inadvertently filed is denied because of client ineligibility.
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