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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2 Overview of Medicaid Managed Care : 2.9 Claims Filing for Managed Care Services

2.9
Claims for services administered by an MCO or dental plan must be submitted to the client’s MCO or dental plan. Providers may submit the managed care claims either of the following ways:
Providers who submit claims directly to the MCO or dental plan must follow the guidelines established by the MCO or dental plan for claims submissions. Providers must contact the appropriate MCO or dental plan for information about filing electronic or paper claims directly to the MCO or dental plan.
Refer to:
The TMHP website at www.tmhp.com/Pages//Medicaid/Medicaid_Managed_Care.aspx for additional information, including MCO and dental plan contact information.
Providers also have the option to submit STAR, STAR+PLUS, STAR Health, and Children’s Medicaid Dental Services claims to TMHP using TexMedConnect or the TMHP EDI Gateway. These claims are automatically routed to the appropriate MCO or dental plan based on the client’s eligibility on file.
Note:
TMHP will not forward electronic claim submissions for pharmacy benefits, NorthSTAR, CHIP, or long term care services, and TMHP will not forward any managed care paper claim submissions. These submissions must be submitted directly to the MCO or dental plan that administers the client’s Medicaid managed care benefits.
To submit MCO and dental plan claims to TMHP for proper routing:
Note:
Each claim must contain services administered by a single entity, either all fee-for-service (including services for fee-for-service clients and carve-out services), all MCO services, or all dental plan services. Fee-for-service procedures and MCO procedures for the same client cannot be billed on the same claim. Each claim may be submitted individually or in a batch. Each batch may contain claims destined for a variety of plans including fee-for-service and managed care.
Providers receive a message that indicates whether the claim was transmitted successfully or unsuccessfully. The provider can correct the submission and submit the claim until the transmission is successful.
Once the claims have been transmitted successfully, the portal will route each claim to the appropriate entity based on the client’s eligibility on file. For MCO and dental plan claims, the provider will receive an electronic claim transmission report that indicates the claim was accepted or rejected by the MCO or dental plan:
If the claim has been accepted, the provider will receive no more transmissions from TMHP. Notices for payment determinations and all payments will be sent to the provider by the MCO or dental plan according to their individual practices and procedures.
If the claim has been rejected by the MCO or dental plan, the provider will receive an electronic claim status report, and will be able to correct the submission and submit the claim until the transmission is successful.
Important:
Providers must call the client’s MCO or dental plan who processed the claim for information about the MCO’s or dental plan’s explanation of benefits (EOB), claims payment, claim rejection, how to correct a rejected claim, or any other questions about the MCO or dental plan claim guidelines and processes. TMHP does not have any information about the MCO’s or dental plan’s claims, benefits, or processes.
Electronic claims submitted to TMHP require an NPI. If an electronic claim is submitted without an NPI, the claim will be denied. If a claim is submitted electronically with a TPI instead of the NPI, the claim will be denied.
For assistance with enrollment for filing eligible electronic claims to TMHP, providers can contact the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions to TMHP.
Subsection 6.3.4, “National Drug Code (NDC)” in Section 6, “Claims Filing” (Vol. 1, General Information), for NDC requirements.
Reminder:
Claims for Medicaid managed care clients must be submitted to the MCO or dental plan in which the client is enrolled at the time of service (or date of admission for inpatient hospital claims). The MCO or dental plan, as a payor of last resort, does not determine payment based on the primary payor’s (i.e., TPR or other primary source of insurance) authorization of services or approval of hospital stays.
Refer to:
The TMHP Medicaid Managed Care web page at www.tmhp.com/Pages/Medicaid/Medicaid_Managed_Care.aspx for additional information.

Texas Medicaid & Healthcare Partnership
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