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 Medicare/Medicaid Dual-Eligibility Claims

Some Medicaid clients are also covered by Medicare and Medicare Advantage Plans (MAP). Medicaid claims for these clients may be reimbursed after the Medicare or MAP portion is paid. This page provides the information providers need to file these claims correctly.

Medicare Parts A and B

Providers are allowed to file Medicare primary paper claims to TMHP for payment of coinsurance and/or deductible for claims that fail to cross over from Medicare electronically. Providers that submit a paper crossover claim must submit a completed claim form along with a Medicare Remittance Advice Notice (MRAN) in one of the following approved formats:

  • MREP
  • PC-Print
  • Paper MRAN from Medicare or a Medicare intermediary
  • TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template Instructions (for MAP clients only)

Paper crossover claims that contain multiple MRAN forms with conflicting information are returned to the provider or denied.

Medicare Part C/Medicare Advantage Plan (MAP) Information

HHSC now contracts with the MAPs and offers a per-client-per-month payment. The payment to the MAP includes all costs associated with the Medicaid cost sharing for dual-eligible clients. TMHP does not reimburse the co-payment, coinsurance, or deductible amounts for these claims. MAPs that contract with HHSC will reimburse providers directly for the cost sharing obligations that are attributable to dual-eligible clients enrolled in the MAP. These payments are included in the capitated rate paid to the HMO and must not be billed to TMHP or a Medicaid client.

Click here to view a list of MAPs that have contracted with HHSC. The list will be updated as additional plans initiate contracts.


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