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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.1 Claims Information : 6.1.1 TMHP Processing Procedures

TMHP processes claims for services rendered to Texas Medicaid fee-for-service clients and carve-out services rendered to Medicaid managed care clients.
Claims for services rendered to a Medicaid managed care client must be submitted to the managed care organization (MCO) or dental plan that administers the client’s managed care benefits. Only claims for those services that are carved-out of managed care can be submitted to TMHP.
Refer to:
The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for more information about carve-out services.
Medicaid claims are subject to the following procedures:
Claims filed under the same provider identifier and program and ready for disposition at the end of each week are paid to the provider with an explanation of each payment or denial. The explanation is called the Remittance and Status (R&S) Report, which may be received as a downloadable portable document format (PDF) version or on paper. A Health Insurance Portability and Accountability Act (HIPAA)-compliant 835 transaction file is also available for those providers who wish to import claim dispositions into a financial system.
An R&S Report is generated for providers that have weekly claim or financial activity with or without payment. The report identifies pending, paid, denied, and adjusted claims. If no claim activity or outstanding account receivables exist during the time period, an R&S Report is not generated for the week.
For services that are billed on a claim and have any benefit limitations for providers, the date of service determines which provider’s claims are paid, denied, or recouped. Claims that have been submitted and paid may be recouped if a new claim with an earlier date of service is submitted, depending on the benefit limitations for the services rendered.
Services that have been authorized for an extension of the benefit limitation will not be recouped. Providers can submit an appeal with medical documentation if the claim has been denied.

Texas Medicaid & Healthcare Partnership
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