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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 4: Client Eligibility : 4.4 Restricted Medicaid Coverage : 4.4.2 Client Limited Program : 4.4.2.8 Limited Status Claims Payment

4.4.2.8
Payment for services to a limited Medicaid client is made to the designated provider only, unless the services result from a designated provider referral or emergency. An automated review process determines if the claim includes the limited primary care provider’s provider identifier as the billing, performing, or referring provider. If the limited primary care provider’s provider identifier is not indicated on the claim, the claim is not paid. Exceptions to this rule include emergency care and services that are included in subsection 4.4.2.2, “Exceptions to Limited Status” in this section. Appeals for denied claims are submitted to TMHP and must include the designated Medicaid provider identifier for reimbursement consideration.
Claims for provider services for Texas Medicaid fee-for-service clients must include the provider identifier for the designated primary care provider as the billing or performing provider or a referral number in the prior authorization number (PAN) field.

Texas Medicaid & Healthcare Partnership
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