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42.7 Claims Information
42.7.1 Other Insurance
Medicaid guidelines state that other insurance carriers must be billed before billing the Texas Medicaid Program. If the SHARS student has other insurance, the SHARS provider can call the other insurance company to inquire whether the service is covered under the student's insurance plan. If the service is not covered under the student's insurance plan, the SHARS provider can obtain from the other insurance company a verbal denial without ever billing the other insurance carrier.
To appeal a Medicaid claim that was denied for other insurance using a verbal denial from the other insurance company, the SHARS provider should submit the following information:
• The date of the telephone call with the other insurance company.
•The name and telephone number of the insurance carrier.
•The name of the insurance representative.
•Policy and group holder information.
•The specific reason for denial.
Include the client's type of coverage to enhance the accuracy of future claims processing.
If the SHARS provider learns that the other insurance policy does cover the service, the SHARS provider must obtain parental permission to bill the other insurance carrier. If parental permission is not received or the SHARS provider does not wish to pursue payment through the other insurance carrier, the SHARS provider cannot bill the Texas Medicaid Program by submitting claims for the services to TMHP.
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