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Claims Processing to Change for Medicaid-Only Services Provided to Dual-Eligible Medicaid Clients Enrolled in 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.

For dates of service on or after September 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will forward claims for Medicaid-only services to the MCOs of dual-eligible Medicaid clients (clients who are eligible for both Medicare and Medicaid) for processing. TMHP will no longer adjudicate the claims, the claim response will show that the claims were forwarded, and no Electronic Remittance and Status (ER&S) Report will be generated by TMHP.

Providers should submit claims for services rendered to Medicaid dual-eligible clients directly to the MCO. Providers should contact the MCOs directly for adjudication information on forwarded claims.

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