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Reminder: Claims Filing for Opioid Treatment Providers

Last updated on 2/28/2020

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.

Reminder: Beginning January 1, 2020, Substance Abuse and Mental Health Services Administration certified (SAMHSA-certified) opioid treatment providers (OTPs) that are also licensed as narcotic treatment programs in Texas are required to enroll in Medicare and re-enroll with Texas Medicaid as OTPs to bill Medicare as the primary payer for clients who have dual eligibility for Medicaid and Medicare. Some of these providers are currently enrolled with Texas Medicaid as chemical dependency treatment facilities (CDTFs).

Important: CDTFs cannot bill for OTP services through Medicare, as CDTFs are not Substance Abuse and Mental Health Services Administration certified (SAMHSA-certified) OTPs.

Providers may refer to the previous enrollment article titled “Beginning December 14, 2019, Opioid Treatment Providers May Submit Texas Medicaid Enrollment Applications,” that was published on the TMHP website on December 2, 2019, for further information.

Claims for Dual Eligible Clients

Section 2005 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. 115-271, the SUPPORT Act), effective January 1, 2020, requires Medicare to pay for OTP services that are provided by Medicare-enrolled OTP providers. Medicare is generally liable as the primary payer for claims for Medicare-covered services. Effective January 1, 2020, Medicaid can no longer pay for OTP services for clients who have dual eligibility for Medicaid and Medicare, as they are now Medicare-covered services.

Medicaid providers that are SAMHSA-certified and licensed in Texas to provide the associated OTP services, but are not currently enrolled in Medicare, must now enroll in Medicare to bill Medicare as the primary payer.

Once providers have completed Medicare enrollment and subsequent re-enrollment in Medicaid under the new OTP identifier, providers billing claims for dual-eligible clients must first submit their claims to Medicare.

Effective on or after January 1, 2020, for claims previously paid for dual eligible clients using the CDTF provider identifier, claims will be reprocessed, and payments recouped with explanation of benefits (EOB) 00026, “Client is eligible for Medicare Part A, B, or C. Medicare must be billed first. Please review client eligibility to determine which Medicare carrier to bill,” which will be reflected on future Remittance and Status (R&S) Reports.

Providers are strongly encouraged to complete the Medicare enrollment and Medicaid re-enrollment process as soon as possible to receive their new OTP identifiers and begin submitting claims for OTP services with the new provider identifiers.

Note: Once enrolled as a Medicaid OTP, an OTP is assigned a new opioid treatment facility provider identifier for all future Medicaid claims for all clients.

For more information, call the TMHP Contact Center at 800-925-9126.