Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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.
Effective April 1, 2022, additional replacement files for the January 2022 first quarter National Correct Coding Initiative (NCCI) edits will be implemented for claims processed by Texas Medicaid & Healthcare Partnership (TMHP) for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.
Claims that were affected by the Centers for Medicare & Medicaid Services (CMS) effective date of the replacement files and processed by TMHP from January 1, 2022, through March 31, 2022, will be reprocessed. Payments may be decreased for NCCI code pairs that have been added or increased for NCCI code pairs that have been deleted.
Providers may refer to the CMS website for updated Medicaid NCCI rules, relationships, and general information. A link to the CMS Medicaid NCCI website is also available on the Rate and Code Updates – NCCI Updates webpage on TMHP.com.
Providers are encouraged to monitor the CMS website regularly for updates to Medicaid NCCI rules and guidelines.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.