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Review of Inpatient Claims for Spell-of-Illness Limitation

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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.

Texas Medicaid is conducting a utilization review of inpatient claims with dates of service from September 26, 2021, through August 21, 2023, to determine whether the claims were paid outside the spell-of-illness limitation, which is 30 days of inpatient hospital care.

When these claims are reprocessed, any payments that were made in excess may be deducted from future payments (recouped). Deductions will appear on future Remittance and Status (R&S) Reports.

For information about the spell-of-illness limitation and exceptions to it, providers can refer to the Texas Medicaid Provider Procedures Manual, Inpatient and Outpatient Hospital Services Handbook.

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