Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
The Texas Health and Human Services Commission (HHSC) has identified an error that occurred during the public health emergency (PHE) that wrongly ended some clients’ eligibility on or after March 1, 2020.
HHSC has directed the Texas Medicaid & Healthcare Partnership (TMHP) to reprocess all claims for dates of service on or after March 1, 2020, for the affected clients. When the claims are reprocessed, providers may receive additional payment, which will be reflected on the Remittance and Status (R&S) Report.
HHSC is directing TMHP to reprocess any prior authorizations in which providers were not aware of retroactive eligibility changes or impacts.
Providers may have received prior authorization (PA) denials, or their PA requests may have been returned due to late submission or failure to file the PAs per the retro-eligibility process.
Important: Providers must review their denied or returned PAs. In order for TMHP to reprocess them, providers must resubmit the PAs with the alert FMAP-Retroactive Eligibility Change.
For more information, call the TMHP Contact Center at 800-925-9126.