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Reprocessing of Claims for Clients with Presumptive Eligibility
Information posted November 6, 2009: TMHP has identified an issue that impacts claims submitted for services provided to clients with presumptive eligibility (PE) and maternity diagnosis codes. Claims might have been denied in error with an explanation of benefits (EOB) message that indicated the services were not payable to clients determined to be presumptively eligible. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action by the provider is necessary. Click on the title to view the affected diagnosis codes with their corresponding dates of service.

Claims with the following dates of service and diagnosis codes will be reprocessed, and payments will be adjusted accordingly.

Diagnosis Codes – Dates of Service on or After October 1, 2006

64900

64902

64903

64904

64910

64912

64913

64914

64920

64922

64923

64924

64930

64932

64933

64934

64940

64942

64943

64944

64950

64953

64960

64962

64963

64964

 

Diagnosis Codes – Dates of Service on or After October 1, 2008

64970

64973

67800

67803

67810

67813

67900

67902

67903

67904

67910

67912

67913

67914

V1521

V2385

V2386

V2830

V2881

V2882

V2889

V8901

V8902

V8903

V8904

V8905

V8909

 

Diagnosis Codes – Dates of Service on or After October 1, 2009

67010

67012

67014

67020

67022

67024

67030

67032

67034

67080

67082

67084

Reminder: Medicaid-covered services during the PE period are limited to medically necessary services provided during pregnancy and certain preventive services such as family planning. Labor, delivery, inpatient services, and Texas Health Steps (THSteps) medical or dental services are not covered during the PE period.

Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, section 4.3.4, “Presumptive Eligibility (PE),” for additional information about clients who are presumptively eligible, and PE guidelines for providers. : Post on the TMHP home page

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