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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.6 Provider Responsibilities : 1.6.9 Billing Clients

A provider cannot require a down payment before providing Medicaid-allowable services to eligible clients, bill, nor take recourse against eligible clients for denied or reduced claims for services that are within the amount, duration, and scope of benefits of Texas Medicaid if the action is the result of any of the following provider-attributable errors:
Failure to submit a claim to TMHP for initial processing within the 95‑day filing deadline (or the initial 365‑day deadline, if applicable)
Submission of an unsigned or otherwise incomplete claim such as omission of the Hysterectomy Acknowledgment Statement or Sterilization Consent Form with claims for these procedures
Failure to appeal a claim within the 120‑day appeal period. Errors made in claims preparation, claims submission, or appeal process
Providers must certify that no charges beyond reimbursement paid under Texas Medicaid for covered services have been, or will be, billed to an eligible client. Federal regulations prohibit providers from charging clients a fee for completing or filing Medicaid claim forms. Providers are not allowed to charge TMHP for filing claims. The cost of claims filing is part of the usual and customary rate for doing business.
Medicaid reimbursement is considered as payment in full for those services covered under Texas Medicaid. In accordance with 1 TAC §354.1005, the reimbursement for services is intended to cover the costs for a covered service, or any function incidental to the provision of a covered service, including, but not limited to:
Signing, completing, or providing a copy of a health assessment form, such as a physical examination form required for the eligible client’s enrollment in school or participation in school or other activities;
If the provider has already provided the eligible client a free copy of the medical record within a one-year period, the provider is required to provide only the amended, supplemented, or corrected portion of the record, if requested, without having to copy the entire record.
A provider may bill or otherwise charge a client a reasonable fee for providing a paper copy of a medical record outside of the above scenarios. A reasonable fee for providing a paper copy of the requested records shall be a charge of no more than $25.00 for the first twenty pages and $.50 per page for every copy thereafter per 22 TAC §165.2.
Completion of required forms submitted by a nursing facility to the physician for signature is also considered incidental to a covered service. It is not acceptable for the physician to charge Texas Medicaid clients, their family, or the nursing facility for telephone calls, telephone consultations, or signing forms.
In accordance with current federal policy, Texas Medicaid and Texas Medicaid clients cannot be charged for the client’s failure to keep an appointment. Only billings for services provided are considered for payment. Clients may not be billed for the completion of a claim form, even if it is a provider’s office policy.
Letters of inquiry about client billing are sometimes sent to providers in lieu of telephone calls from TMHP representatives. In either case, it is mandatory that the questions be answered with the requested pertinent information. Upon receipt, TMHP forwards these letters to HHSC. HHSC uses the information to resolve client billing/liability issues. It is mandatory that these letters be signed, dated, and returned within ten business days.
Refer to:
Subsection 4.6, “Medically Needy Program (MNP)” in “Section 4: Client Eligibility” (Vol. 1, General Information).
Private Pay Agreement on the TMHP website at

Texas Medicaid & Healthcare Partnership
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