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December 2016 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 9 * Carve-Out Services : 9.1 Family Planning Carve-Out Services : 9.1.1 Professional and Outpatient Claims

9.1.1
For affected claims to be eligible for reimbursement through TMHP, providers must do the following:
1)
Submit the claim to the client’s managed care health plan in order to receive the health plan’s denial. Claims that are submitted electronically using TexMedConnect will automatically be forwarded to the client’s Medicaid managed care plan.
2)
Submit a paper claim to TMHP upon receipt of the health plan’s denial. All applicable documentation must be included with the paper claim, including, but not limited to:
The health plan’s EOB document that indicates the denial code with its description and the date the EOB was issued. The denial must indicate that the service was denied because it was a family planning service. The EOB date will be used to calculate the filing deadline for the claim submission.
All documentation for family planning services including Sterilization Consent Forms and Hysterectomy Acknowledgements Forms, and any other documentation that is required by Texas Medicaid.
Note:
A paper claim is required because TMHP automatically forwards electronic claims to the client’s health plan without processing. Providers must comply with all filing deadlines unless otherwise specified below in this article.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.