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8.6.2 Medicare Denied
All claims denied by Medicare for administrative reasons must be appealed to Medicare before they are sent to the Texas Medicaid Program.
An assigned claim that was denied by Medicare because the client has no Part B benefits or because the transport destination is not allowed can be submitted to TMHP for consideration.
Providers must send claims to TMHP on a CMS-1500 claim form with the ambulance provider identifier, unless they are a hospital-based provider. Hospital-based ambulance providers must send Medicare denied claims to TMHP on a CMS-1500 claim form with the ambulance provider identifier and a copy of the MRAN.
Note: All claims for STAR+PLUS clients with Medicare and Medicaid should follow the same requirements used for obtaining prior authorization for Medicaid-only services from TMHP. The STAR+PLUS HMO is not responsible for reimbursement of these services.
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