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Dual Eligible PA Requirements for Medicaid-Only Services

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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.

Reminder: If a service requires prior authorization (PA) through Medicaid and the service is not a benefit of Medicare, providers may request PA from the Texas Medicaid & Healthcare Partnership (TMHP) before receiving the denial from Medicare. This applies to dual-eligible clients enrolled in either the Medicaid fee-for-service program or the Medicaid managed care program.

Providers may refer to the Texas Medicaid Provider Procedures Manual, Section 5: Fee-For-Service Prior Authorizations Handbook, subsection 5.1.5, “Prior Authorization Requests for Clients with Medicare/Medicaid,” for additional information regarding clients with dual eligibility.

When Medicaid receives a claim with a valid Health and Human Services Commission (HHSC) Social Security Administration (SSA) reject code, it will be reprocessed as a regular Medicaid claim. If a claim has been denied by Medicare because the services are not a benefit of Medicare or the Medicare benefits have been exhausted, providers can submit a paper claim to TMHP. The paper claim may be submitted for the following reimbursements:

  • Coinsurance reimbursement
  • Deductible reimbursement
  • Reimbursement for the Medicaid-only services that were denied by Medicare

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