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

   
 

6.12.1.2 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
Description

CP001

Private HMO copayment-professional

CP002

Private PPO copayment-professional

CP003

Medicare HMO copayment-professional

CP004

Medicare PPO copayment-professional

POS 5 - Outpatient
Description

CP005

Private HMO copayment-outpatient

CP006

Private PPO copayment-outpatient

CP007

Medicare HMO copayment-outpatient

CP008

Medicare PPO copayment-outpatient


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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