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December 2016 Texas Medicaid Provider Procedures Manual

Section 8: Third Party Liability (TPL) : 8.8 Other Insurance Claims Filing : 8.8.3 Claims Forwarded to Other Insurance Carriers

Federal and state laws require the use of Medicaid funds for the payment of most medical services only after all reasonable measures have been made to use a client’s TPR or other insurance. Providers are required to submit clients’ known other insurance to TMHP.
TMHP forwards electronic institutional claims for clients suspected of having other insurance to a contractor. The contractor researches the claims to determine the client’s possible other insurance information. If it is determined that the client has valid other insurance for the claim’s date of service and the insurance carrier is listed below, the contractor will forward the claim to the selected insurance carrier.
Provider will receive a denial EOB from TMHP on the R&S Report that will indicate that the claim was forwarded to the client’s other insurance carrier.
If the other insurance carrier denies the claim, the provider should first exhaust all avenues to appeal the claim with the other insurance carrier. If the final disposition is a denial, the provider may appeal the claim to TMHP using the carrier’s EOB showing the denial. Providers must review their R&S Reports to ensure that any follow-up action is taken within the appeal deadlines.
TMHP will not forward the following claim types to the contractor:
Refer to:
Subsection, “Filing Deadlines” in “Section 6: Claims Filing” (Vol. 1, General Information) for information about filing deadlines for clients with other insurance.

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