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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 7: Appeals : 7.2 Refunds to TMHP : 7.2.1 Refunds Resulting from Other Insurance Payments

7.2.1
Providers are prohibited from receiving payment from Medicaid, billing a TPR, and then refunding the lesser of the two payments to Medicaid.
Refunds owed to TMHP must not be held until the end of an accounting year. If within 12 months of the date of service a provider identifies a TPR and wants to submit a claim for payment, the provider must refund any amounts previously paid by TMHP before submitting the claim to the third party.
If private insurance paid for the services submitted on the claim, the provider must provide the exact amount paid, the insurance company’s name and address, and the client’s policy number and group number.
Providers are limited to the Medicaid payable amount and are required to accept the amount paid by TMHP as payment in full if:
Third party payments received after receipt of the TMHP payment must be refunded to TMHP in full, even if the amount paid by the third party insurer exceeds the Medicaid payment.
If the amount paid by a third party health insurer is less than the amount payable for the service by Medicaid, providers may bill TMHP for the difference between the amount paid by the third party health insurer and the Medicaid payable amount if the claim is filed timely and in accordance with all the applicable rules.
In accordance with Title 1 Texas Administrative Code (TAC) §§354.2321 [g] and 354.2322 [i], providers that do not follow TPR rules “may be referred for investigation and prosecution for violations of state or federal Medicaid or false claims laws.” Providers should refer to the full text of these rules for a full description of payment requirements.

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