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Claims Reprocessing for Some CLIA Denied Claims

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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.

The Texas Medicaid & Healthcare Partnership (TMHP) has identified an issue related to claims that may have been denied due to an error in the Provider Enrollment and Management System (PEMS). The error was caused by Clinical Laboratory Improvement Amendments (CLIA) numbers that were deleted from the program practice record in PEMS. The issue was fixed on July 13, 2023.

TMHP will reprocess any affected claims that are identified with dates of service on or after April 15, 2023. Providers only have to appeal claims if the claims are denied for additional reasons after reprocessing is completed.

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