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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 4: Client Eligibility

Section 4: Client Eligibility
4.1 General Medicaid Eligibility 4-3
4.1.1 Retroactive Eligibility 4-3
4.1.2 Expedited Eligibility (Applies to Medicaid-eligible Pregnant Women
Throughout the State ) 4-4
4.1.3 Medicaid Buy-In Program for Employed Individuals with Disabilities 4-4
4.1.4 Newborn Eligibility 4-4
4.1.5 Potential Supplemental Security Income (SSI)/Medicaid Eligibility for
Premature Infants 4-5
4.1.6 Foster Care 4-5
4.1.7 Medicaid Managed Care Eligibility 4-6
4.2 Eligibility Verification 4-6
4.2.1 Advantages of Electronic Eligibility Transactions 4-6
4.3 Medicaid Identification and Verification 4-7
4.4 Restricted Medicaid Coverage 4-8
4.4.1 Emergency Only 4-8
4.4.2 Client Limited Program 4-8
4.4.2.1 Limited Medicaid Identification 4-9
4.4.2.2 Exceptions to Limited Status 4-9
4.4.2.3 Selection of Designated Provider and Pharmacy 4-10
4.4.2.4 Pharmacy services 4-11
4.4.2.5 Duration of Limited Status 4-11
4.4.2.6 Referral to Other Providers 4-12
4.4.2.7 Hospital Services 4-12
4.4.2.8 Limited Status Claims Payment 4-12
4.4.3 Hospice Program 4-13
4.4.3.1 Hospice Medicaid Identification 4-13
4.4.3.2 Physician Oversight Services 4-13
4.4.3.3 Medicaid Services Unrelated to the Terminal Illness 4-13
4.4.4 Presumptive Eligibility (PE) 4-14
4.4.4.1 PE Medicaid Identification 4-14
4.4.4.2 Services 4-14
4.4.4.3 Qualified Provider Enrollment 4-14
4.4.4.4 Process 4-15
4.5 CHIP Perinatal Program 4-15
4.5.1 Program Benefits 4-16
4.5.2 Claims 4-16
4.5.3 Client Eligibility Verification 4-16
4.5.3.1 Confirming Receipt of Form H3038 4-17
4.5.3.2 Eligibility Verification for Clients Without a Medicaid ID 4-17
4.5.3.3 Mother’s eligibility 4-18
4.5.3.4 Newborn’s eligibility 4-18
4.5.4 Submission of Birth Information to Texas Vital Statistics Unit 4-18
4.6 Medically Needy Program (MNP) 4-18
4.6.1 Spend Down Processing 4-19
4.6.2 Closing an MNP Case 4-20
4.7 Medicaid Buy-in for Children (MBIC) Program 4-21
4.8 Texas Medicaid Wellness Program 4-21
4.9 Women’s Health Program (WHP) 4-22
4.10 Medicaid for Breast and Cervical Cancer (MBCC) 4-22
4.10.1 Initial MBCC Program Enrollment 4-23
4.10.2 MBCC Program Eligibility 4-23
4.10.3 Continued MBCC Program Eligibility 4-23
4.11 Medicare and Medicaid Dual Eligibility 4-24
4.11.1 QMB/MQMB Identification 4-24
4.11.2 Medicare Part B Crossovers 4-24
4.11.3 Clients Without QMB or MQMB Status 4-25
4.11.4 Medicare Part C 4-25
4.12 Contract with Outside Parties 4-25
4.13 Third Party Liability (TPL) 4-25
4.13.1 Your Texas Benefits Medicaid Card 4-27
4.13.2 Workers’ Compensation 4-27
4.13.3 Adoption Cases 4-27
4.13.4 THSteps TPR Requirements 4-28
4.13.5 Accident-Related Claims 4-28
4.13.5.1 Accident Resources, Refunds 4-28
4.13.6 Third Party Liability - Tort 4-29
4.13.6.1 Providers Filing Liens for Third Party Reimbursement 4-30
4.13.6.2 Informational Claims 4-31
4.13.6.3 Submission of Informational Claims 4-31
4.13.6.4 Informational Claim Converting to Claims for Payment 4-31
4.14 Health Insurance Premium Payment (HIPP) Program 4-32
4.15 Long-Term Care Providers 4-32
4.16 State Supported Living Centers 4-32
4.17 Forms 4-33
4.1 Your Texas Benefits Medicaid Card - Your New Medicaid ID (English) 4-34
4.2 Your Texas Benefits Medicaid Card - Your New Medicaid ID (Spanish) 4-35
4.3 Informational Claims Submission Form 4-36
4.4 Other Insurance Form 4-37
4.5 Authorization for Use and Release of Health Information (2 pages) 4-38
4.6 Authorization for Use and Release of Health Information (Spanish) (2 pages) 4-40
4.7 Tort Response Form 4-42

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.