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December 2016 Texas Medicaid Provider Procedures Manual

Section 8: Third Party Liability (TPL) : 8.3 TPR Sources : 8.3.1 Exceptions

8.3.1
Certain funding sources are an exception to TPR. Adoption agencies or foster parents are not considered a TPR. Medicaid is primary in the STAR Health program (except when court-ordered to provide health insurance). This is an exception to the rule that Medicaid is payer of last resort. Providers must not bill other health insurance unless there is a court order that places this responsibility elsewhere. For Texas Health Steps (THSteps), providers must refer to the MCO, or dental plan that administers the client’s managed care benefits for additional information.
Refer to:
Non-TPR sources are secondary to Texas Medicaid and may only pay benefits after Texas Medicaid. The following are the most common non-TPR sources:
If providers have questions about others not listed, they may contact a provider relations representative.
Note:
Claims for clients who are seeking disability determination must be submitted to DARS for consideration of reimbursement. Refer to the DARS website at www.dars.state.tx.us for additional information about disability determinations and claims filing.
Denied claims or services that are not a benefit of Medicaid may be submitted to non-TPR sources.
If a claim is submitted inadvertently to a non-TPR source listed above before submission to TMHP, the claim may be submitted to TMHP within the filing deadlines.
Refer to:
If a non-TPR source erroneously makes a payment for a dual-eligible client for services also covered by Medicaid, the payment is refunded to the non-TPR source.

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