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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 : 2.9.3 System Requirements for MCO and Dental Plan Claim Submissions Through TMHP

Before a claim can be routed to the MCO or dental plan through TMHP’s electronic claims filing system, TMHP must certify that both the system the provider uses to submit the claim and the system the MCO or dental plan uses to receive the claim are compatible with the EDI 5010 standard.
Refer to:
Subsection 3.7, “Third Party Vendor Implementation” in Section 3, “TMHP Electronic Data Interchanges (EDI)” (Volume 1, General Information), for information about EDI 5010 compatibility and certification.
MCOs or dental plans must also complete trading partner testing with TMHP to certify EDI 5010 compatibility and verify that routed claims can be received. Providers that submit claims through TMHP to MCOs or dental plans that have not completed trading partner testing will receive a claim rejection.
If the system requirements are not met, providers must submit claims directly to the MCO or dental plan using the MCO’s or dental plan’s established methods for claims submission. Providers must contact the client’s MCO or dental plan with questions about the MCO’s or dental plan’s billing guidelines and methods.
Use of TMHP’s electronic claim submission system is optional. Providers may continue to submit claims directly to the appropriate MCO or dental plan. Regardless of submission method, adjudication and reimbursement for managed care services is the responsibility of the appropriate MCO or dental plan and not TMHP.

Texas Medicaid & Healthcare Partnership
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