TMPPM 2008 > Provider Information > Managed Care > Medicaid Managed Care

7.1.9 Claims Filing Information

TMHP processes claims for the following clients/programs:

•All PCCM claims (whether TANF or SSI).

•All SSI clients who are in the STAR Program

•The following services for PCCM, STAR+PLUS, or STAR clients:

•ECI Case Management.

•DSHS case management (except for the Dallas SA where clients are enrolled in NorthSTAR).

•DADS services (except for the Dallas SA where clients are enrolled in NorthSTAR).

•CPW Case Management.

•SHARS.

•DARS.

•THSteps Dental (dentist services only).

•Tuberculosis services provided by DSHS-approved providers.

•Vendor Drug Program (out-of-office drugs).

•Audiology services and hearing aids for children under the age of 21 (hearing screening services are provided through the THSteps Program and are capitated) through the Program for Amplification for Children of Texas (PACT).

A claim must be submitted to TMHP for processing for a patient who was classified as SSI on the date of admission to a hospital. However, if the patient was an HMO client as of the date of admission to the hospital and was admitted as TANF- (i.e., not SSI) certified, but changed to SSI during the same hospital stay, the claim must be submitted to the client's HMO for payment of the entire hospital stay.

If the provider of services is not the client's assigned primary care provider, the primary care provider's name and provider identifier must be entered in the Referring Provider field of the approved electronic format, in boxes 17 and 17a of the CMS-1500 claim form, or boxes 78 and 79 of the UB-04 CMS-1450 claim form, indicating a referral from the primary care provider. If this information is missing and the treating provider is not the assigned primary care provider on the dates of service, the claim will be denied.

Providers submitting claims for SSI voluntary clients must follow the client's individual plan requirements for referrals, authorization, admission notification, and concurrent review. The plan is responsible for notifying TMHP of the services that they have approved so those claims can be processed accordingly. Claims for SSI clients who are voluntarily enrolled in PCCM or an HMO will be paid at traditional Medicaid rates.

All traditional Medicaid processing guidelines are followed in processing these claims including the 95-day filing deadline. Send claims through regular mail to the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200555
Austin, TX 78720-0555

Claims delivered by UPS or other courier methods are to be addressed to the following:

Texas Medicaid & Healthcare Partnership
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727

TMHP Electronic Claims Submission

Electronic claims submission is available to providers filing claims for PCCM clients and all SSI voluntary clients in STAR HMOs. Providers must use their provider identifier when billing. For assistance with enrolling to file electronic claims, contact the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638, or a provider representative. Contact individual plans for information on electronic claims submissions to STAR HMOs (refer to chart, STAR Program SAs).

Refer to: "TMHP Electronic Data Interchange (EDI)" for more information about electronic claims submission.