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TMHP Claims System to Be Updated for Inpatient Hospital Transfer 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.

Beginning December 6, 2024, the Texas Medicaid & Healthcare Partnership (TMHP) will update the system used to process inpatient hospital claims for Medicaid clients.

If a patient's eligibility changed from Medicaid fee-for-service to an MCO (or vice versa) while they received inpatient hospital care, the initial hospital must bill the program (Medicaid fee-for-service or MCO) that the client was enrolled in at the time of admission.

If a patient is transferred, the hospital of transfer must bill the program (Medicaid fee-for-service or MCO) that the patient was enrolled in on the date of transfer. The hospital of transfer cannot bill the program that the patient was enrolled in prior to the transfer.

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