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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 : 9.1.1.1 Claim Forms for Submission to TMHP

9.1.1.1
After receiving the health plan’s denial, Medicaid family planning services providers should submit paper claim forms to TMHP as follows:
Providers that do not contract with the HHSC Family Planning Program should submit claims on a CMS-1500 paper claim form along with the health plan’s denial.
Providers should submit the health plan’s EOB document that indicates the denial code with its description and the date that 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.
Providers must comply with all filing deadlines.
The initial paper claim will be denied by TMHP. TMHP will automatically reprocess for payment consideration any claim that has been denied only with EOB 00081, “Services billed to TMHP in error. Bill HMO.”
TMHP will reprocess only those claims that were denied with EOB 00081 as the only EOB message on the claim. If a claim has been denied with other EOB messages in addition to EOB 00081, the provider must resolve the other reasons for denial through the standard appeals process before TMHP can reprocess the claim for payment of the carved-out services.

Texas Medicaid & Healthcare Partnership
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