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Review of Inpatient Claims for Spell-of-Illness Limitation

Last updated on 7/31/2020

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.

Texas Medicaid is conducting a utilization review of inpatient claims with dates of service from June 9, 2018, through May 19, 2020, to determine whether the claims were paid outside of the spell-of-illness limitation, which is 30 days of inpatient hospital care.

Impacted inpatient hospital claims paid in excess of the spell-of-illness limitation will be retroactively denied or adjusted. When these claims are reprocessed, any payments made in excess may be deducted from future payments (i.e., recouped). Deductions will be reflected on future Remittance and Status (R&S) Reports.

For information about the spell-of-illness limitation and exceptions to it, providers can refer to the Texas Medicaid Provider Procedures Manual, "Inpatient and Outpatient Hospital Services Handbook.”

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