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Claims Filing Tips for Providers

Last updated on 6/7/2021

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.

Due to recent system changes, Texas Medicaid & Healthcare Partnership (TMHP) is experiencing delays in processing incoming United States Postal Service mail. TMHP will maintain the original receipt date for the documents and this will be used to determine if documents were received within the claims filing limitations.

Note: It is strongly recommended that providers who submit paper claims keep a copy of the documentation they send. It is also recommended that paper claims be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which is particularly important if it is necessary to prove that the 95-day claims filing deadline has been met.

TMHP will accept certification receipts as proof of the 95-day or 120-day filing deadline. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, date of service, and a signed claim copy. The provider needs to keep such proof of multiple claims submissions if the provider identifier is pending.

Electronic Filing: Faster Access to Claims

Providers can participate in the most efficient and effective method of submitting claims to TMHP by submitting claims electronically. Electronic filing also allows for faster access to claims. Providers that file paper claims are encouraged to switch to electronic submission.

Providers should allow 30 business days for claims processing to be completed before contacting TMHP to check on the status of their claims submission.

After filing a claim to TMHP, providers should review the weekly Remittance and Status Report. If within 30 business days the claim does not appear in the Claims in Process section, or if it does not appear as paid, denied, or as an incomplete claim, providers should resubmit the claim to TMHP within 95 days of the date of service.

Refer to: The current Texas Medicaid Provider Procedures Manual, Volume 1, Claims Filing, subsection 6.1.4.6, “Claims Filing Reminders,” for additional information.

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