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December 2016 Texas Medicaid Provider Procedures Manual

Section 8: Third Party Liability (TPL) : 8.8 Other Insurance Claims Filing : 8.8.2 Other Insurance Credits : 8.8.2.5 110-Day Rule

8.8.2.5
When a service is billed to a third party and no response has been received, Medicaid providers must allow 110 days to elapse before submitting a claim to TMHP. If a TPR has not responded or delays payment or denial of a provider’s claim for more than 110 days after the date the claim was billed, Medicaid considers the claim for reimbursement. However, the 365-day federal filing deadline requirement must still be met. The following information is required:
When TMHP denies a claim because of the client’s other coverage, information that identifies the other insurance appears on the provider’s Remittance and Status (R&S) Report. The claim is not to be refiled with TMHP until disposition from the TPR has been received or until 110 days have lapsed since the billing of the claim with no disposition from the TPR. A statement from the client or family member which indicates that they no longer have this resource is not sufficient documentation to reprocess the claim.
When a provider is advised by a TPR that benefits have been paid to the client, the information must be included on the claim with the date and amount of payment made to the client if available. If a denial was sent to the client, refer to the verbal denial guidelines above for required information. This enables TMHP to consider the claim for reimbursement.

Texas Medicaid & Healthcare Partnership
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