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

4.10.6 Refunds to TMHP Resulting from Other Insurance Payments and Conditions Surrounding Provider Billing of Third Party Insurers

Providers are prohibited expressly from receiving payment from Medicaid, billing a TPR, and then refunding to Medicaid the lesser of the two payments. This section outlines some portions of those rules that providers must follow when billing third party insurers. This summary does not include all the TPR provisions to which providers must adhere; thus, providers review the complete text of Title 1 Texas Administrative Code (TAC) §§354.2321 and 354.2322 for a full description of provider requirements surrounding recovery from third parties.

Any refunds due to TMHP are not to be held until the end of an accounting year. Because providers must accept assignment, they must accept Medicaid payment as payment in full for covered services and they may not use payment by another TPR to make up the difference between the amount billed and the Medicaid payment. Any payment received from another TPR must be refunded to TMHP if the following conditions are not met.

Providers who identify a TPR within 12 months from the date of service, and wish to submit a claim for payment to a third party health insurer after a claim for payment has been submitted to and paid by TMHP, must refund any amounts paid by TMHP before submitting a claim for payment to the third party.

Providers are limited to the Medicaid payable amount and are required to accept the amount paid by TMHP as payment in full if:

•A claim for payment is submitted to and paid by TMHP.

•The provider failed to refund TMHP before submitting a claim for payment to a third party as outlined in the third paragraph above.

Third party payments received after receipt of the TMHP payment must be refunded to TMHP in full, even if the amount paid by the third party insurer exceeds the Medicaid payment.

If the amount paid by a third party health insurer is less than the amount payable for the service by Medicaid, providers may bill TMHP for the difference between the amount paid by the third party health insurer and the Medicaid payable amount, if a claim was filed timely and in accordance with all the applicable rules.

In accordance with the TPR rules (1 TAC §§354.2321 [g] and 354.2322 [i]), "any provider who accepts Medicaid payment as payment in full for services and retains any amount in excess of the Medicaid payable amount from a third party and conceals or fails to account to the department for the third party amount, resulting in excessive or duplicate payment for the same service, may be referred for investigation and prosecution for violations of state and/or federal Medicaid or false claims laws."

When making TPR refunds, providers should make the check payable to TMHP and send it with a completed Refund Information Form addressed to the attention of TMHP Cash Reimbursement.

Include the following information with the TPR refund:

•Client name and Medicaid number.

•Copy of the R&S report listing the paid claim (if available).

•Date of service.

•Provider name, number, or both.

•Name and address of the attorney or casualty insurance company (including the policy and claim number).

•Subscriber information.

•Amount of insurance payment.

Refer to: "Texas Medicaid Refund Information Form".