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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.13 Medicare Claims : 6.13.5 Paper Crossovers

6.13.5
The following paper crossover claims may be submitted to TMHP:
For QMB and MQMB clients, crossover claims that are not transferred to TMHP electronically through the COBC. (Providers can submit a paper claim to TMHP for coinsurance and deductible reimbursement consideration.)
For MQMB clients, claims that are denied by Medicare because the services are not a benefit of Medicare or because Medicare benefits have been exhausted. (Providers can submit a paper claim to TMHP for coinsurance and deductible reimbursement consideration, and reimbursement consideration for the denied services. The Medicare EOB that contains the relevant claim denial must be submitted to TMHP with the completed claim from within 95 days from the Medicare disposition date and 365 days from the date of service. The denied services will be processed as Medicaid-only services. )
Important:
The paper submission must include all of the following:
The appropriate TMHP Standardized Medicare and MAP Remittance Advice Notice Form (i.e., MRAN/MAP template). (The MRAN/MAP template is optional when certain conditions are met.)

Texas Medicaid & Healthcare Partnership
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