Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Beginning February 1, 2019, TMHP will update the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Section 5.3.1, “Eligibility for Texas Health Steps Services and Checkup Due Dates.” The update will remove language associated with Medicaid managed care timely medical checkup reports.
The language TMHP will remove contains requirements applicable only to Managed Care Organizations (MCOs). It is not applicable Texas Medicaid providers. These reporting requirements will remain applicable to MCOs and are specified in the MCO’s contract with Texas Health and Human Services.
TMHP will remove the following language from the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Section 5.3.1, “Eligibility for Texas Health Steps Services and Checkup Due Dates”:
MCOs are also required to assure existing members of their health plan meet eligibility requirements and receive timely medical checkups. A checkup for an existing member from birth through 35 months of age is timely if received within 60 days beyond the periodic due date based on the client’s birth date. For existing members 36 months of age and older, a checkup is due beginning on the child’s birthday and is considered timely if it occurs within 364 calendar days after the child’s birthday in a non-leap year or 365 days after the child’s birthday in a leap year. Checkups received before the periodic due date are not reportable as timely medical checkups. Providers should contact the appropriate MCO for further details.
For more information, call the TMHP Contact Center at 800-925-9126.