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Professional Claims Submitted With Procedure Code 59514 Must Be Submitted to CHIP MCOs

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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.

Effective December 1, 2023, providers that submit professional claims with procedure code 59514 must submit the claims directly to the Children’s Health Insurance Program (CHIP) managed care organizations (MCOs).

Claims submitted to the Texas Medicaid & Healthcare Partnership (TMHP) after December 1, 2023, will be denied with Explanation of Benefits (EOB) message 01152: “The submitted labor with delivery professional procedure is a CHIP perinatal benefit. Please bill the appropriate CHIP perinatal health plan.”

Medicaid will no longer pay these claims unless the claim is appealed and a claims nurse determines that the service was medically necessary and that emergency Medicaid coverage criteria were met.

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