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Claims Reprocessing for Some New Patient Visits

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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 that impacts claims submitted for new patient visits within three rolling years of a new or established patient visit with the same provider.

These claims may have been processed incorrectly. Affected claims submitted with dates of service from December 1, 2023, through November 30, 2024, will be reprocessed, and payments may be deducted from future payments (recouped). Any deductions will be reflected in Remittance and Status (R&S) Reports.

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