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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 : 2.9.2 Filing Deadlines

2.9.2
The following table summarizes the filing deadlines that apply for MCO and dental plan claim submissions:
 
95 days of the date on the Remittance and Status (R&S) Report from the other (wrong) carrier (documentation of timely filing is required)
Initial submission to TPR (not the Medicaid MCO or dental plan)
Claims must be submitted to the appropriate entity whether TMHP or the MCO or dental plan within 95 days of the date of service. If the claim is not received by the MCO or dental plan within 95 days, the claim will be denied.
If the provider files with the wrong plan within the 95 day submission requirement (e.g., State Claims Administrator but not with the MCO or dental plan), the provider must resubmit the claim with documentation that shows the claim was submitted within the appropriate time frame but to the wrong plan. The MCO or dental plan must honor the initial filing date and process the claim without denying the resubmission for the sole reason of passing the filing timeframe. The provider must file the claim with the correct MCO within 95 days of the date on the Remittance and Status (R&S) Report from the other (wrong) carrier.
When a service is billed to other insurance, the claim must be refiled and received by the Medicaid MCO or dental plan within 95 days from the date of disposition by the other insurance resource. The MCO or dental plan will determine, as a part of its provider claims filing requirements, the documentation required when a provider refiles these types of claims with the MCO or dental plan.
MCOs and dental plans are subject to the requirements related to coordination of benefits for secondary payers in the Texas Insurance Code section 843.349 (e) and (f).
Refer to:
Subsection 2.9, “Claims Filing for Managed Care Services” in this handbook for details about MCO claims processed by TMHP and not the client’s MCO.

Texas Medicaid & Healthcare Partnership
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