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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 : 2.9.1 Newborn Claims Filing for MCO Services

Newborns are automatically assigned to the MCO in which the mother is enrolled at the time of the newborn’s birth. The effective date of the newborn’s enrollment is the same as the newborn’s date of birth. Claims for services provided to newborns should be filed with the mother’s MCO. Health-care providers should file newborn claims using the newborn’s Medicaid identification number as soon as the number is made available. Providers filing claims for services provided to newborns are still responsible for meeting the Medicaid filing deadlines, which in most cases is within 95 days of each date of service.
MCOs must pay providers for inpatient and professional services related to neonatal care for up to 48 hours after vaginal delivery and 96 hours after Cesarean delivery. (Prior authorizations and PCP assignment cannot be a reason for denial of claims.)
MCOs may require prior authorizations for hospital and professional services beyond the 48-hour and 96-hour time limits.
Authorization requests, utilization review questions, and claim status inquiries and appeals should be directed to the MCO in which the client is enrolled.
Telephone numbers and addresses for MCO claims submission and appeals can be found in the appropriate MCO provider policies and procedures manual for the appropriate service area.

Texas Medicaid & Healthcare Partnership
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