TMPPM 2008 > Provider Information > Client Eligibility > Third Party Resources (TPR)

4.10 Third Party Resources (TPR)

Federal and state laws require the use of Medicaid funds for the payment of most medical services only after all reasonable measures have been made to use a client's TPR or other insurance.

A TPR is a source of payment for medical services other than Medicaid or Medicaid managed care organization (MCO), the client, and non-TPR sources. TPR includes payments from any of the following sources:

•Private health insurance including assignable indemnity contracts.

•Health maintenance organization (HMO).

•Public health programs available to clients with Medicaid such as Medicare and Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

•Profit and nonprofit health plans.

•Self-insured plans.

•No-fault automobile insurance such as personal injury protection (PIP) and automobile medical insurance.

•Liability insurance.

•Life insurance policies, trust funds, cancer policies, or other supplemental policies.

•Workers' Compensation.

•Other liable third parties.

Reminder: Adoption agencies/foster parents are no longer considered a TPR. Medicaid is primary in these circumstances.

Non-TPR sources are secondary to Texas Medicaid and may only pay benefits after the Texas Medicaid Program. The following are the most common non-TPR sources. If providers have questions about others not listed, they may contact a provider relations representative.

•Department of Assistive and Rehabilitative Services (DARS), Blind Services.

•Texas Kidney Health Care Program.

•Crime Victims' Compensation Program.

•Muscular Dystrophy Association.

•CSHCN Services Program.

•Texas Band of Kickapoo Equity Health Program.

•Maternal and Child Health (Title V).

•State Legalization Impact Assistance Grant (SLIAG).

•Adoption Agencies.

•Home and Community-based Waivers Programs through the Department of Aging and Disability Services (DADS).

Denied claims or services that are not a benefit of Medicaid may be submitted to non-TPR sources.

If a claim is submitted inadvertently to a non-TPR source listed above before submission to TMHP, the claim may be submitted to TMHP using the filing deadlines identified under "Filing Deadlines" .

If a non-TPR source erroneously makes a payment for a dual-eligible for services also covered by Medicaid, the payment is refunded to the non-TPR source.

Any indemnity insurance policy that pays cash to the insured for wages lost or for days of hospitalization rather than for specific medical services is considered a TPR if the policy is assignable to someone else. HHSC has assignment to any Medicaid applicant's or client's right of recovery from TPRs, to the extent of the cost of medical care services paid by Medicaid. The Texas Medicaid Program requires a provider take all reasonable measures to use a client's TPRs before billing Medicaid.

A provider who furnishes services and participates in the Texas Medicaid Program may not refuse to furnish services to an eligible client because of a third party's potential liability for payment of the services.

Eligible clients may not be held responsible for billed charges that are in excess of the TPR payment for services covered under the Texas Medicaid Program. If the TPR pays less than the Medicaid-allowable amount for covered services, the provider should submit a claim to TMHP for any additional allowable amount. Additionally, eligible clients enrolled in private HMOs must not be charged the copayment amount because the provider has accepted Medicaid assignment.