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Claims Reprocessing for Pregnant Women Presumptive Eligibility

Last updated on 11/16/2020

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.

TMHP has identified an issue with presumptive eligibility claims for pregnant women. Claims submitted with dates of service on or after January 1, 2020, may have been denied.

Affected claims submitted with dates of service on or after January 1, 2020, may be reprocessed. When the claims are reprocessed, providers may receive additional payment, which will be reflected on Remittance and Status (R&S) Reports.

Presumptive eligibility claims for pregnant women will be held up to 60 days to allow for final Medicaid eligibility determination to process to avoid duplication in payment between TMHP and the MCO to the presumptive eligibility provider. A presumptive eligibility provider may receive the following explanation of benefits message while client’s eligibility is being checked:

“THE CLIENT'S ELIGIBILITY IS BEING RESEARCHED.”

If no managed care determination was processed within the 60-day hold period, the claim will be then be processed by TMHP under current Medicaid policy guidelines.

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