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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 4: Client Eligibility : 4.13 Third Party Liability (TPL)

4.13 Third Party Liability (TPL)
Federal and state laws require the use of Medicaid funds for the payment of most medical services only after all reasonable measures have been made to use a client’s third party resources (TPR) or other insurance.
To the extent allowed by federal law, a health-care service provider must seek reimbursement from available third party insurance that the provider knows about or should know about before billing Texas Medicaid. All claims for clients with other insurance coverage must reference the information (see subsection 6.12, “Other Insurance Claims Filing” in Section 6, “Claims Filing” [Vol. 1, General Information]), regardless of whether a copy of the EOB from the insurance company is submitted with the claim.
Refer to:
Subsection 7.2, “Refunds to TMHP” in Section 7, “Appeals” (Vol. 1, General Information) for information regarding refunds to TMHP resulting from other insurance payments and conditions surrounding provider billing of third party insurers.
Eligible clients enrolled in private HMOs must not be charged the co-payment amount because the provider has accepted Medicaid assignment.
A provider who furnishes services and participates in Texas Medicaid may not refuse to furnish services to an eligible client because of a third party’s potential liability for payment of the services.
A TPR is a source of payment for medical services other than Medicaid, the client, and non-TPR sources. TPR includes payments from any of the following sources:
Reminder:
Refer to:
Subsection 4.13.4, “THSteps TPR Requirements” in this section for THSteps TPR exceptions.
Family planning (including Title XIX and the DSHS Family Planning Program) services providers cannot bill a client’s TPRs before filing the claim with TMHP. Federal regulations protect the client’s confidential choice of birth control and family planning services. Confidentiality is jeopardized when seeking information from TPRs.
SHARS providers are not required to file claims with private insurance before billing Medicaid.
Early Childhood Intervention (ECI) providers are not required to file claims with private insurance before billing Medicaid for Targeted Case Management services.
Case Management for Children and Pregnant Women providers are not required to file claims with other health insurance before filing with Medicaid.
Non-TPR sources are secondary to Texas Medicaid and may only pay benefits after Texas Medicaid. The following are the most common non-TPR sources. If providers have questions about others not listed, they may contact a provider relations representative.
Note:
Claims for clients who are seeking disability determination must be submitted to DARS for consideration of reimbursement. Refer to the DARS website at www.dars.state.tx.us for additional information about disability determinations and claims filing.
Denied claims or services that are not a benefit of Medicaid may be submitted to non-TPR sources.
If a claim is submitted inadvertently to a non-TPR source listed above before submission to TMHP, the claim may be submitted to TMHP using the filing deadlines identified under subsection 6.1.4, “Claims Filing Deadlines” in Section 6, “Claims Filing” (Vol. 1, General Information).
If a non-TPR source erroneously makes a payment for a dual-eligible client for services also covered by Medicaid, the payment is refunded to the non-TPR source.
Any indemnity insurance policy that pays cash to the insured for wages lost or for days of hospitalization rather than for specific medical services is considered a TPR if the policy is assignable to someone else. HHSC has assignment to any Medicaid applicant’s or client’s right of recovery from a third party health insurer, to the extent of the cost of medical care services paid by Medicaid. Texas Medicaid requires a provider take all reasonable measures to use a client’s TPR before billing Medicaid.
Medicaid-eligible clients may not be held responsible for billed charges that are in excess of the TPR payment for services covered by Texas Medicaid. If the TPR pays less than the Medicaid-allowable amount for covered services, the provider should submit a claim to TMHP for any additional allowable amount.

Texas Medicaid & Healthcare Partnership
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