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December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility : 4.1 General Medicaid Eligibility : 4.1.2 Retroactive Eligibility

Medicaid coverage may be assigned retroactively for a client. For claims for an individual who has been approved for Medicaid coverage but has not been assigned a Medicaid client number, the 95‑day filing deadline does not begin until the date the notification of eligibility is received from HHSC and added to the TMHP eligibility file.
The date on which the client’s eligibility is added to the TMHP eligibility file is the add date. To ensure the 95‑day filing deadline is met, providers must verify eligibility and add date information by calling the Automated Inquiry System (AIS) or using the TMHP Electronic Data Interchange (EDI) electronic eligibility verification.
If a person is not eligible for medical services under Texas Medicaid on the date of service, reimbursement for all care and services provided must be resolved between the provider and the client receiving the services. Providers are not required to accept Medicaid for services provided during the client’s retroactive eligibility period and may continue to bill the client for those services. This guideline does not apply to nursing facilities certified by the Department of Aging and Disability Services (DADS).
If it is the provider’s practice not to accept Medicaid for services provided during the client’s retroactive eligibility period, the provider must apply the policy consistently for all clients who receive retroactive eligibility. Providers must inform the client about their policy before rendering services. If providers accept Medicaid assignment for the services provided during the client’s retroactive eligibility period and want to submit a claim for Medicaid-covered services, providers must refund payments received from the client before billing Medicaid for the services.
The provider should also check the eligibility dates electronically through TexMedConnect or the Your Texas Benefits Medicaid card website at to see whether the client has retroactive eligibility for previous bills. Retroactive eligibility and the retroactive eligibility period may be verified by visiting Texas Medicaid considers all services between the Eligibility Date and the Good Through date for reimbursement. Providers can determine whether a client has retroactive eligibility for previous bills by verifying eligibility on, transmitting an electronic eligibility request, or calling AIS or the TMHP Contact Center.
Examples of Medicaid identification forms are found at the end of this section. Actual Medicaid forms can be identified by a watermark.
Refer to:

Texas Medicaid & Healthcare Partnership
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