Information posted March 25, 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 is committed to helping providers ensure continuity of care during the COVID-19 (coronavirus) response. Providers are highly encouraged to transition from paper prior authorization (PA) submission and claims billing to using TMHP’s free and secure electronic systems to submit PAs and claims.
Prior Authorization on the Portal
Prior Authorization on the Portal allows for real-time submissions and the ability to view and respond to pending action. Providers can upload all attachments and information related to the request. Requests can be saved as a draft to be continued later, and providers will receive immediate confirmation of submitted information. To save time, providers can create templates for similar authorization requests.
Providers can access Prior Authorization on the Portal from the TMHP Prior Authorization webpage. To learn more about submitting PA requests electronically using Prior Authorization on the Portal, providers can access the following resources:
- Texas Medicaid Provider Procedures Manual (TMPPM), section 5.5.1, “Prior Authorization Requests Through the TMHP Website.”
- Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, section 4.3.6, “Prior Authorization Electronic Submissions through the TMHP Prior Authorization on the Portal.”
- PA on the Portal Submission Guide.
Electronic Claims Submission Options
Electronic billing provides a faster response to claims filing by giving a claim status update within 24 hours and a response within a week. TMHP’s electronic claims submission software, and most third-party claims submission software, will alert users to mistakes, which allows users to make corrections and reduces the number of rejected and denied claims. Appeals to denied claims can also be filed electronically.
Providers that want to file claims electronically can use one of the following methods:
- TMHP’s electronic claims submission software TexMedConnect.
- Vendor software to submit files directly to TMHP.
- A billing agent to submit claims on the provider’s behalf:
- An up-to-date list of billing agents who have completed the testing process and certified by TMHP can be found on the Approved Vendors List on the EDI Vendor Testing webpage.
More information about electronic claims filing can be found in the following resources:
- TMHP Portal Security Provider Training Manual.
- TMHP Claims Submission Video.
- Texas Medicaid Provider Procedures Manual (TMPPM), section 6.2, “TMHP Electronic Claims Submission.”
- Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, section 41.3, “Electronic Billing.”
A user name and password are required to access training material on the TMHP Learning Management System (LMS). Providers can refer to the Learning Management System (LMS) Registration Job Aid for detailed steps to register for the LMS.
For help with TexMedConnect, contact the Electronic Data Interchange (EDI) Help Desk at 888-863-3638.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.