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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 : 6.1.4.6 Claims Filing Reminders

6.1.4.6
After filing a claim to TMHP, providers should review the weekly R&S Report. If within 30 days the claim does not appear in the Claims In Process section, or if it does not appear as a paid, denied, or incomplete claim, the provider should resubmit it to TMHP within 95 days of the DOS.
The provider should allow TMHP 45 days to receive a Medicare‑paid claim automatically transmitted for payment of deductible or coinsurance.
Electronic billers should notify TMHP about missing claims when:
Certain claims, including those that were submitted for newborn services or that might be covered under Medicare, are suspended for review so that other state agencies can verify information. This review may take longer than 60 days.
These suspended claims will appear on the provider’s R&S Report under “The following claims are being processed” with a message indicating that the client’s eligibility is being investigated. Providers must wait until the claim is finalized and appears under “Paid or Denied” or “Adjustment to Claims” on the R&S Report before appealing the claim. If the claim does not appear on the R&S Report, providers must resubmit the claim to TMHP to ensure compliance with filing and appeal deadlines.

Texas Medicaid & Healthcare Partnership
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