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December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility : 4.3 Medicaid Identification and Verification

4.3
Providers are responsible for requesting and verifying current eligibility information from clients by using the methods listed in subsection 4.2, “Eligibility Verification” in this section or by asking clients to produce their Your Texas Benefits Medicaid card or Medicaid Identification form (H1027).
Providers may verify client eligibility electronically through TexMedConnect or through the Medicaid eligibility verification website at www.YourTexasBenefitsCard.com from which website providers can print a copy of a client’s proof of eligibility.
Providers must accept either of these forms as valid proof of eligibility. Providers should retain a copy for their records to ensure the client is eligible for Medicaid when the services are provided. Clients should share eligibility information with their providers.
Providers should request additional identification if they are unsure whether the person presenting the form is the person identified on the form.
Providers should check the Eligibility Date to see whether the client has possible retroactive eligibility for previous bills.
Only those clients listed on the Medicaid Eligibility form or the Your Texas Benefits Medicaid card are eligible for Medicaid. If a person insists he or she is eligible for Medicaid but cannot produce a current Your Texas Benefits Medicaid card or Medicaid Eligibility Verification (Form H1027), has lost it, or has forgotten to bring it to the appointment, providers can verify eligibility through the methods listed in subsection 4.2, “Eligibility Verification” in this section. Providers must document this verification in their records and treat these clients as if they had presented a Your Texas Benefits Medicaid card or Medicaid Eligibility Verification (Form H1027).
When a client’s Your Texas Benefits Medicaid care has been lost or stolen, HHSC issues a temporary Medicaid verification Form H1027. The following is a sample of forms:
Form H1027A. Medicaid eligibility verification is used to indicate eligibility for clients who receive regular Medicaid coverage.
Form H1027B. Medicaid Qualified Medicare Beneficiary (MQMB) is issued to clients eligible for MQMB coverage.
Form H1027C. Qualified Medicare Beneficiary (QMB) is issued to clients who are eligible for QMB coverage only.
Form H1027F. Temporary Medicaid identification for clients receiving Former Foster Care in Higher Education (FFCHE) health care.
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The Medicaid Eligibility Verification (Form H1027) is acceptable as evidence of eligibility during the eligibility period specified unless the form contains limitations that affect the eligibility for the intended service. Providers must accept any of the documents listed above as valid proof of eligibility. If the client is not eligible for medical assistance or certain benefits, the client is treated as a private-pay patient.
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Providers must review limitations identified on the Medicaid electronic eligibility file, AIS, the Your Texas Benefits Medicaid card website at www.YourTexasBenefitsCard.com, or the Medicaid Eligibility Verification (Form H1027). Clients may be required to use a designated primary provider or pharmacy. QMB clients will be limited to Medicaid coverage of the Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare coinsurance or deductible according to current payment guidelines.
If the client is identified as eligible and no other limitations of eligibility affect the intended service, proceed with the service. Eligibility during a previous month does not guarantee eligibility for the current month. The Medicaid Eligibility Verification (Form H1027) and the Your Texas Benefits Medicaid card are the only documents that are honored as verification of Medicaid eligibility.
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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 claims 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.

Texas Medicaid & Healthcare Partnership
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