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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.1 Claims Information : 6.1.4 Claims Filing Deadlines

For claims payment to be considered, providers must adhere to the time limits described in this section. Claims received after the following claims filing deadlines are not payable because Texas Medicaid does not provide coverage for late claims.
Unless otherwise stated below, claims must be received by TMHP within 95 days of each DOS. Appeals must be received by TMHP within 120 days of the disposition date on the R&S Report on which the claim appears. A 95‑day or 120‑day appeal filing deadline that falls on a weekend or a holiday is extended to the next business day following the weekend or holiday.
Only the following holidays extend the deadlines in 2016 and 2017:
* Federal holiday, but not a state holiday. The claims filing deadline will be extended for providers because the Post Office will not be operating on this day.
The following are time limits for submitting claims:
Hospitals that are reimbursed according to diagnosis-related group (DRG) payment methodology may submit an interim claim because the client has been in the facility 30 consecutive days or longer. A total stay claim is needed after discharge to ensure accurate calculation for potential outlier payments for clients who are 20 years of age and younger.
Hospitals that are reimbursed according to Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 methodology may submit interim claims before discharge and must submit an interim claim if the client remains in the hospital past the hospital’s fiscal year end.
Providers that are enrolling in Texas Medicaid for the first time or are making a change that requires the issuance of a new TPI, such as a change of ownership, can submit claims within 95 days from the date their TPI is issued as long as claims are submitted within 365 days of the date of service.
TMHP must receive claims on behalf of an individual who has applied for Medicaid coverage but has not been assigned a Medicaid number on the DOS within 95 days from the date the eligibility was added to the TMHP eligibility file (add date) and within 365 days of the date of service or from the discharge date for inpatient claims.
Providers should verify eligibility and add date by contacting TMHP (Automated Inquiry System [AIS], TMHP EDI’s electronic eligibility verification, or TMHP Contact Center) when the number is received. Not all applicants become eligible clients. Providers that submit claims electronically within the 365-day federal filing deadline for services rendered to individuals who do not currently have a Texas Medicaid identification number will receive an electronic rejection. Providers can use the TMHP rejection report as proof of meeting the 365-day federal filing deadline and submit an administrative appeal.
Providers should request and keep hard copies of any Medicaid Eligibility Verification (Form H1027) submitted by clients or proof of client eligibility from the Your Texas Benefits Medicaid card website at A copy is required during the appeal process if the client’s eligibility becomes an issue.
If a client becomes retroactively eligible or loses Medicaid eligibility and is later determined to be eligible, the 95‑day filing deadline begins on the date that the eligibility start date was added to TMHP files (the add date). However, the 365-day federal filing deadline must still be met.
When a service is a benefit of Medicare and Medicaid, and the client is covered by both programs, the claim must be filed with Medicare first. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition.
Providers must submit a paper MRAN received from Medicare or a Medicare intermediary, the computer-generated MRANs from the CMS-approved software application MREP for professional services or PC-Print for institutional services, or the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template with a completed claim form to TMHP.
When a client is eligible for Medicare Part B only, the inpatient hospital claim for services covered as Medicaid only is sent directly to TMHP and is subject to the 95‑day filing deadline (from date of discharge).
It is strongly recommended that providers who submit paper claims keep a copy of the documentation they send. It is also recommended that paper claims be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which is particularly important if it is necessary to prove that the 95‑day claims filing deadline has been met. TMHP will accept certification receipts as proof of the 95‑day or 120‑filing deadline. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. The provider needs to keep such proof of multiple claims submissions if the provider identifier is pending.
If the provider is attempting to obtain prior authorization for services performed or will be performed, TMHP must receive the claim according to the usual 95‑day filing deadline.
The provider bills TMHP directly within 95 days from the DOS. However, if a non-third party resource (TPR) is billed first, TMHP must receive the claim within 95 days of the claim disposition by the other entity.
The provider submits a copy of the disposition with the claim. A non-TPR is secondary to Texas Medicaid and may only pay benefits after Texas Medicaid.
Refer to:
When a service is billed to another insurance resource, the filing deadline is 95 days from the date of disposition by the other resource.
When a service is billed to a third party and no response has been received, Medicaid providers must allow 110 days to elapse before submitting a claim to TMHP. However, the 365‑day federal filing deadline requirement must still be met.
A Compass21 (C21) process allows an HHSC Family Planning claim to be paid by Title XIX (Medicaid) if the client is eligible for Title XIX when those services are provided and billed under the HHSC Family Planning Program. In this instance, the Medicaid 95‑day filing deadline is in effect and must be met or the claim will be denied.
In accordance with federal regulations, all claims must be initially filed with TMHP within 365 days of the DOS, regardless of provider enrollment status or retroactive eligibility.
Refer to:
Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for information on the provider enrollment process.
Subsection 7.1, “Appeal Methods” in “Section 7: Appeals” (Vol. 1, General Information) for information on the process for submitting appeals.
Subsection, “Exceptions to the 95‑Day Filing Deadline” in this section.
Subsection A.12.3, “Automated Inquiry System (AIS)” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information) to learn how to retrieve client eligibility information by telephone.
Refer to:
Subsection 4.2, “Eligibility Verification” in “Section 4: Client Eligibility” (Vol. 1, General Information).
Subsection 6.11.6, “Provider Inquiries—Status of Claims” in this section.

Texas Medicaid & Healthcare Partnership
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