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5.1.4 Claims Filing Deadlines
For questions or assistance about the Texas Medicaid Program, call the TMHP Contact Center at 1-800-925-9126.
For claims payment to be considered, providers must adhere to the time limits described in this section. Claims received after the following claims filing deadlines are not payable because the Texas Medicaid Program does not provide coverage for late claims.
Exception: The Texas Administrative Code (TAC) allows HHSC to consider exceptions to the 95-day filing deadline under special circumstances. Unless otherwise stated below, claims must be received by TMHP within 95 days from each date of service (DOS). Appeals must be received by TMHP within 120 days of the disposition date on the R&S report on which the claim appears. A 95-day or 120-day appeal filing deadline that falls on a weekend or a holiday is extended to the next business day following the weekend or holiday.
Only the following holidays extend the deadlines in 2008:
The following are time limits for submitting claims:
• Inpatient claims filed by the hospital must be received by TMHP within 95 days from the discharge date or last DOS on the claim.
•Hospitals reimbursed according to diagnosis-related group (DRG) payment methodology may submit an interim claim because the client has been in the facility 30 consecutive days or longer. A total stay claim is needed after discharge to ensure accurate calculation for potential outlier payments for clients younger than 21 years of age.
•Children's hospitals reimbursed according to Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 methodology may submit interim claims before discharge and must submit an interim claim if the client remains in the hospital past the hospital's fiscal year end.
•When medical services are rendered to a Medicaid client in Texas, TMHP must receive claims within 95 days of the DOS on the claim. Claims submitted by newly enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the DOS.
•TMHP must receive claims from out-of-state providers within 365 days from the DOS. The DOS is the date the service is provided or performed.
•TMHP must receive claims on behalf of an individual who has applied for Medicaid coverage but has not been assigned a Medicaid number on the DOS within 95 days from the date the eligibility was added to the TMHP eligibility file (add date) and within 365 days of the date of service. Providers should verify eligibility and add date by contacting TMHP (Automated Inquiry System [AIS], TMHP EDI's electronic eligibility verification, or TMHP Contact Center) when the number is received. Not all applicants become eligible clients.
Important: Providers should request and keep copies of any Forms 1027 and H3087 submitted by clients. A copy is required during the appeal process if the client's eligibility becomes an issue.
•If a client becomes retroactively eligible or loses Medicaid eligibility and is later determined to be eligible, the 95-day filing deadline begins on the date that the eligibility start date was added to TMHP files (the add date).
•When a service is a benefit of Medicare and Medicaid, and the client is covered by both programs, the claim must be filed with Medicare first. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition. Providers submit the TMHP Standardized MRAN Form or the computer-generated MRANs from the Centers for Medicare & Medicaid Services (CMS)-approved software application Medicare Remit Easy Print (MREP) for professional services or PC-Print for institutional services with a completed claim form to TMHP.
•When a client is eligible for Medicare Part B only, the inpatient hospital claim for services covered as Medicaid only is sent directly to TMHP and subject to the 95-day filing deadline (from date of discharge).
Note: It is strongly recommended that providers who submit paper claims keep a copy of the documentation they send. It is also recommended paper claims be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which is particularly important if it is necessary to prove that the 95-day claims filing deadline has been met. TMHP will accept certification receipts as proof of the 95-day and/or 120-filing deadline. For this, the provider must provide the following: certification receipt, log to include information in the packet, Medicaid number, billed amount, and a signed claim copy. The provider needs to keep such proof about multiple claims submissions if the provider identifier is pending.
•If the provider is trying to obtain prior authorization for services performed or will be performed, TMHP must receive the claim according to the usual 95-day filing deadline.
•The provider bills TMHP directly within 95 days from the DOS. However, if a non-third party resource (TPR) is billed first, TMHP must receive the claim within 95 days of the claim disposition by the other entity. The provider submits a copy of the disposition with the claim. A non-TPR is secondary to Texas Medicaid and may only pay benefits after the Texas Medicaid Program.
Refer to: "Third Party Resources (TPR)" for examples of non-TPRs.
•When a service is billed to another insurance resource, the filing deadline is 95 days from the date of disposition by the other resource.
•When a service is billed to a third party and no response has been received, Medicaid providers must allow 110 days to elapse before submitting a claim to TMHP. However, the federal 365-day filing requirement must still be met.
•A C21 process allows a Title V, X, or XX Family Planning claim to be paid by Title XIX (Medicaid) if the client is eligible for Title XIX when those services are provided and billed under Title V, X, or XX. In this instance, the Medicaid 95-day filing deadline is in effect and must be met or the claim will be denied.
Note: In accordance with federal regulations, all claims must be initially filed with TMHP within 365 days of the DOS. Refer to: "Claims Filing Instructions" for more information.
"Provider Enrollment" for information on the provider enrollment process.
"Appeal Methods" for information on the process for submitting appeals.
"Exceptions to the 95-Day Filing Deadline" .
"Automated Inquiry System (AIS)" on page vii to learn how to retrieve client eligibility information by telephone.
"Third Party Resources (TPR)" .
"Eligibility Verification" .
"Provider Inquiries-Status of Claims" .
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