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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.7 Managed Care Plan Changes : 2.7.3 Managed Care Organization (MCO) Clients Who Transition to Medicaid Fee-For Service (FFS) : 2.7.3.4 Loss of Eligibility

2.7.3.4
If an MCO disenrolled a client and the client also loses Medicaid eligibility, providers must anticipate, if and when Medicaid eligibility is restored, that the client will initially be considered a Medicaid FFS client and will have a retroactive eligibility period.
All requests for services that require prior authorization and that occur during the client’s retroactive eligibility period, must be submitted to TMHP following the process that is outlined in subsection 5.1.1, “Prior Authorization Requests for Clients with Retroactive Eligibility” in Section 5: Fee‑for‑Service Prior Authorizations (Vol.1, Provider Handbooks).
If a client is retroactively disenrolled by an MCO, all of the services that are rendered by the provider during this retroactive disenrollment period (specifically from the date on which the client was eligible for FFS to the date of the client’s MCO eligibility change) will be denied by TMHP, and the provider will be notified of their administrative appeal rights.
TMHP may consider services for the MCO transition beginning on the date of the client’s MCO eligibility change date and going forward. TMHP uses the MCO transition process for the submission of paperwork and the processing of provider requests.

Texas Medicaid & Healthcare Partnership
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