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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.13 Medically Needy Claims Filing

6.13
TMHP must receive claims for unpaid bills not applied toward spend down within 95 days from the date eligibility was added to the TMHP client eligibility file (add date). These bills must be on the appropriate claim form (for example, CMS‑1500 or UB-04 CMS-1450). Providers are allowed to submit completed CMS claim forms directly to the Medically Needy Clearinghouse (MNC) or to applicants for the Medically Needy Program (MNP) to be used to meet spend down. The completed CMS claim forms used to meet spend down are held for ten calendar days by the MNC, then forwarded to TMHP claims processing. Claims for services provided after the spend down is met must be received within 95 days from the date eligibility is added. Inpatient hospital facility claims must be received within 95 days from the date of discharge or last DOS on the claim. This applies when eligibility is not retroactive.
The client’s payment responsibilities are as follows:
If a portion of one of the bills was used to meet the spend down, the client is responsible for paying the portion applied toward the spend down, unless it exceeds the Medicaid allowable amount.
The claim must show the total billed amount for the services provided. Charges for ineligible days or spend down amounts should not be deducted or noncovered on the claim.
A client’s payment toward spend down is not reflected on the claim submitted to TMHP.
Payments made by the client for services not used in the spend down but were incurred during an eligible period must be reimbursed to the client before the provider files a claim to TMHP.
Services that require prior authorization and are provided before the client becomes eligible for Medicaid by meeting spend down are not reimbursable by Texas Medicaid.
If a bill or a completed CMS claim form was not used to meet spend down and the dates of service are within the client’s eligible period, submit the total bill to TMHP.
When eligibility has been established, a TP 55 with spend down client can receive the same care and services available to all other Medicaid clients. If eligibility is established through TP 30 with spend down, the client’s Medicaid eligibility is restricted to coverage for an emergency medical condition only. Emergency medical condition is defined under Emergency medical condition is defined under subsection 4.4.2.2, “Exceptions to Lock-in Status” in “Section 4: Client Eligibility” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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