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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.11 Remittance and Status (R&S) Report : 6.11.6 Provider Inquiries—Status of Claims

6.11.6
TMHP provides several effective mechanisms for researching the status of a claim. Weekly, TMHP provides the R&S Report reflecting all claims with a paid, denied, or pending status. Providers verify claim status using the provider’s log of pending claims.
Electronic billers allow ten business days for a claim to appear on their R&S Reports. If the claim does not appear on an R&S Report as paid, pending, or denied, a transmission failure, file rejection, or claims rejection may exist. Providers check records for transmission reports correspondence from the TMHP EDI Help Desk.
The provider allows at least 30 days for a Medicaid paper claim to appear on an R&S Report after the claim has been submitted to TMHP. If a claim has not been received by TMHP and must be submitted a second time, the second claim must also meet the 95‑day filing deadline.
The provider allows TMHP 45 days to receive a Medicare-paid claim automatically transmitted for payment of coinsurance or deductible according to current payment guidelines. Claims that fail to cross over from Medicare may be filed to TMHP by submitting a paper MRAN received from Medicare or a Medicare intermediary, the computer generated MRANs from the CMS-approved software applications MREP for professional services or PC-Print for institutional services or, for MAP clients, TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template with the completed claim form.
If the claim does not appear on an R&S Report as paid, pending, or denied, providers can use any of the following procedures to inquire about the status of the claim:
The provider can call AIS at 1‑800‑925‑9126 to determine if the claim is pending, paid, denied, or if TMHP has no record of the claim.
If any of the three options above indicates that TMHP has no record of the claim, the provider can call the TMHP Contact Center at 1‑800‑925‑9126 and speak to a TMHP contact center representative.
If the TMHP Contact Center has no record of a claim that was submitted within the original filing deadline, the provider can submit a copy of the original claim to TMHP for processing. Electronic billers may refile the claim electronically. For claims submitted by a hospital for inpatient services, the filing deadline is 95 days from the discharge date or the last DOS on the claim. For all other types of providers, the filing deadline is 95 days from each DOS on the claim.
If the 95‑day filing deadline has passed and the claim is still within 120 days of the date of the rejection report or the R&S Report, the provider can submit a signed copy of the claim and all of the documentation that supports the original claim submission, including any electronic rejection reports, to:
Texas Medicaid & Healthcare Partnership
Inquiry Control Unit
12357‑A Riata Trace Parkway, Suite 100
Austin, TX 78727
Providers must retain copies of all R&S Reports for a minimum of five years. Providers must not send original R&S Reports back with appeals. Providers must submit one copy of the R&S Report to TMHP per appeal.
Refer to:

Texas Medicaid & Healthcare Partnership
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