Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Section 8: Third Party Liability (TPL) : 8.3 TPR Sources

8.3
A provider who furnishes services and participates in Texas Medicaid may not refuse to furnish services to an eligible client because of a third party’s potential liability for payment of the services.
TPR includes payments from any of the following sources:
Casualty coverage resulting from an accidental injury such as automobile or property insurance (including no-fault insurance); No-fault automobile insurance such as personal injury protection (PIP) and automobile medical insurance
Claims for family planning services (including Title XIX and the Department of State Health Services [DSHS] Family Planning Program) must be submitted to TMHP before billing a client’s TPR . Federal regulations protect the client’s confidential choice of birth control and family planning services. Confidentiality is jeopardized when seeking information from TPRs.
School Health and Related Services (SHARS) providers are not required to file claims with private insurance before billing Medicaid.
Early Childhood Intervention (ECI) providers are not required to file claims with private insurance before billing Medicaid for Targeted Case Management services.
Case Management for Children and Pregnant Women providers are not required to file claims with other health insurance before filing with Medicaid.
THSteps medical and dental providers are not required to bill other insurance before billing Medicaid. If the provider is aware of other insurance, however, the provider must choose whether or not to bill the other insurance. The provider has the following options:
If the provider chooses to bill Medicaid and not the client's other insurance, the provider is indicating acceptance of the Medicaid payment as payment in full. Medicaid then has the right to recovery from the other insurance. The provider does not have the right to recovery and cannot seek reimbursement from the other insurance after Medicaid has made payment.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.