Skip to main content

You must have JavaScript enabled in order to access this part of the site. Please enable JavaScript and then reload this page in order to continue.

HCS and TxHmL Claim Details Cannot Overlap Multiple Service Authorizations

Last updated on

This article has been updated. To view the updated information, see “Update: HCS and TxHmL Claim Details Cannot Overlap Multiple Service Authorizations.”

The Texas Health and Human Services Commission (HHSC) advises Home and Community-based Services (HCS) and Texas Home Living (TxHmL) providers and financial management services agencies (FMSAs) that accurate service utilization budgets are calculated when a claim detail’s dates of service (DOS) do not cross multiple Individual Plan of Care (IPC) service authorization periods. If a billed claim detail has DOS that cross multiple IPC service authorization periods, all claim detail billed units are subtracted from the most recent IPC service authorization period budget. Click here for an example.

New Edit: One IPC Service Authorization Period per Claim Detail

To prevent inaccurate service utilization balances, HHSC is implementing an edit that will deny a claim detail if the DOS crosses multiple IPC service authorization periods. If this denial occurs, the provider or FMSA should submit a new and corrected claim by splitting the claim detail into two claim details, allowing the accurate IPC authorization period to be used to satisfy the number of units billed on each claim detail. The explanation of benefits (EOB) received when the edit is activated is provided in the table below. The edit will be effective July 26, 2023.

EOBEOB Description
F0268A valid service auth. for client for these service dates is not available, or claim dates cannot overlap more than one service auth.

Review Claims if a Service Utilization Balance Appears to Be Incorrect

If a provider or FMSA suspects that an individual’s service utilization balance is inaccurate, or if the provider or FMSA has run out of available units for billing, they should review claims that were billed prior to July 26, 2023, with DOS that cross multiple IPC service authorization periods. Providers and FMSAs can adjust these claims by correcting and splitting the claim into two claim details. Each claim detail’s DOS and number of units billed should correspond to the appropriate IPC service authorization period and number of units available.

Providers and FMSAs can consult the Remittance and Status (R&S) Report, TexMedConnect’s Medicaid Eligibility Service Authorization Verification (MESAV), or the X12 270-271 for help with reconciling billed claim information or checking the client’s service utilization balance.

If you need help with R&S Reports or TexMedConnect:

  • You can find R&S Report information on the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS). Log in, and search for Remittance and Status (R&S) Reports for LTC Providers: A Quick Reference Guide. You can get additional help with R&S Reports on the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waiver Programs YouTube channel.
  • You can find TexMedConnect instructions for MESAV on the TMHP website. On the home page, click Programs, and select Long-Term Care (LTC). Click Reference Material. Under “User Guides,” click Long-Term Care (LTC) User Guide for TexMedConnect.

If you have questions about this article, call the TMHP LTC Help Desk at 800-626-4117, and select option 1 and then option 7.