TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Other Insurance Claims Filing > Other Insurance Credits > HMO Copayments HMO Copayments

TMHP processes and pays HMO copayments for private and Medicare HMOs as well as private and Medicare PPO copayments for clients who are eligible for reimbursement under Medicaid guidelines.

TMHP pays the copayment in addition to the service the HMO or PPO has denied, if the client is eligible for the Texas Medicaid Program and the procedure is reimbursed under Medicaid guidelines. Providers are not allowed to hold the client liable for the copayment.

An office or emergency room (ER) visit (the ER physician is paid only when the ER is not staffed by the hospital) is reimbursed a maximum copayment of $10 per visit. The hospital ER visit is reimbursed at a maximum of $50 to the facility. TMHP pays up to four copayments per day, per client. ER visits are limited to one per day, per client, and are considered one of the four copayments allowed per day.

Important: By accepting assignment on a claim for which the client has Medicaid coverage, providers agree to accept payment made by insurance carriers and the Texas Medicaid Program when appropriate as payment in full. The client cannot be held liable for any balance related to Medicaid-covered services.

The following Medicaid codes have been created for copayments, which are considered an atypical service:

POS 1 - Office


Private HMO copayment-professional


Private PPO copayment-professional


Medicare HMO copayment-professional


Medicare PPO copayment-professional

POS 5 - Outpatient


Private HMO copayment-outpatient


Private PPO copayment-outpatient


Medicare HMO copayment-outpatient


Medicare PPO copayment-outpatient

Texas Medicaid & Healthcare Partnership
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