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December 2016 Texas Medicaid Provider Procedures Manual

Section 8: Third Party Liability (TPL) : 8.10 Refunds Resulting from Other Insurance Payments

8.10
The TMHP Cash Reimbursement Unit is responsible for processing financial adjustments when overlapping payments by Medicaid and a TPR occur.
Providers can use the Texas Medicaid Refund Information Form to:
Refund the overpayment by issuing a check to TMHP. Providers must submit the refund check to TMHP along with the Texas Medicaid Refund Information Form and all required information requested on the form.
Refer to:
The Texas Medicaid Refund Information Form, which is available in the Forms section of the TMHP website at www.tmhp.com.
If the amount paid by the other insurance carrier is less than Medicaid’s allowed amount, providers may bill TMHP for the difference. All claims must meet all timely filing deadlines.
Providers are prohibited from receiving payment from Medicaid and billing a TPR without refunding the Medicaid payment.
If within 12 months of the date of service a provider identifies that the client has other insurance and wants to submit a claim for payment to the other insurance company, the provider must refund any amounts previously paid by TMHP before submitting the claim to the other insurance.
If other insurance paid for the services submitted on the claim, the provider must submit the following to TMHP:
Providers are limited to the Medicaid allowed amount for the services. Providers are required to accept the TMHP paid amount as payment in full. If the provider fails to refund a payment to TMHP before submitting a claim to the other insurance, TMHP will recoup the entire other insurance payment.
In accordance with 1 TAC §§354.2321 [g] and 354.2322 [i], providers that do not follow TPR rules “may be referred for investigation and prosecution for violations of state or federal Medicaid or false claims laws.” Providers should refer to the full text of these rules for a full description of payment requirements.

Texas Medicaid & Healthcare Partnership
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