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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 : 9.1.2 Inpatient Claims

For affected claims to be eligible for reimbursement through TMHP, providers must do the following:
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.
Submit a paper claim to HHSC Administrative Appeals 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.
HHSC Administrative Appeals will send the family planning services inpatient claims to TMHP for reprocessing. Medical portions of the claims will be denied by Texas Medicaid because they are covered under the client’s health plan and will not be considered for reimbursement through TMHP. The services that were denied by the health plan as family planning services will be considered for payment according to Medicaid guidelines.
Refer to:
Section 7: Appeals (Vol. 1, General Information) for additional information about administrative appeals.

Texas Medicaid & Healthcare Partnership
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